Sinusitis. Disclosures. What are sinuses? STEVEN E DAVIS, MD. Consultant and speaker, Novartis Research: Intersect ENT

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1 Sinusitis STEVEN E DAVIS, MD Disclosures Consultant and speaker, Novartis Research: Intersect ENT What are sinuses? Stedman s medical dictionary 25 th edition 1. a channel for the passage of blood or lymph, without the coats of an ordinary vessel; e.g., blood passages in the gravid uterus or those in the cerebral meninges 2. A hollow in bone or other tissue 3. a fistula or tract leading to a suppurating cavity

2 Frontals Ethmoids Maxillaries Clear Sinuses (coronal) Frontals Septum Middle turbinates Inferior turbinates Ethmoids Maxillaries Source: UW radiology at Sphenoid Frontal

3 Clear Sinuses (sagittal) Frontal Ethmoids Sphenoid Inferior turbinate Source: UW radiology at Sinusitis Defined (a work in progress) Acute Rhinosinusitis (ARS) Chronic Rhinosinusitis (CRS) Recurrent Acute Rhinosinusitis (RARS) Acute Exacerbation of Chronic Rhinosinusitis Subacute Rhinosinusitis Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209 Acute Rhinosinusitis Sinonasal inflammation < four weeks Nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior) and facial pain/pressure or reduction/loss of smell with sudden onset of symptoms Acute viral symptoms are generally present for fewer than 10 days Inquire about symptoms suggestive of allergy Sneezing, watery rhinorrhea, nasal and ocular pruritus, and watery eyes Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209

4 Chronic Rhinosinusitis Sinonasal inflammation persisting for more than 12 weeks Nasal obstruction/congestion/blockage, nasal drainage(mucopurulent) that may drain anteriorly or posteriorly, facial pain/pressure/fullness, and decreased or loss of sense of smell Must be accompanied by objective findings Nasal endoscopy (purulence, polyps, or edema) Imaging findings consisting of inflammation or mucosal changes within the sinuses Recurrent Acute Rhinosinusitis (RARS) Four episodes per year of ARS with distinct symptom free intervals between episodes Average adult gets between 1.4 and 2.3 viral URIs per year Diagnosing Acute Rhinosinusitis

5 Diagnosing ARS (acute rhinosinusitis) Diagnosis of ARS is clinical Nasal endoscopy and imaging are not required for diagnosis in uncomplicated cases Based on multiple symptoms nasal congestion or blockage drainage or PND facial pressure/pain reduction in sense of smell Other associated symptoms include sore throat, hoarseness, and cough, as well as non-specific systemic complaints such as malaise, fatigue, and low-grade fever Speculum Exam (anterior rhinoscopy) PHOTO HERE Anterior Rhinoscopy

6 Anterior Rhinoscopy Anterior rhinoscopy is recommended and may reveal evidence of inflammation, mucosal edema, and discharge Diagnostic Sinonasal Endoscopy NORMAL VIDEO HERE Oropharynx

7 Oropharynx - ARS Viral vs. Bacterial ARS VS Viral vs. Bacterial ARS Duration is a key factor in distinguishing ABRS from a common cold Persistence of symptoms beyond 10 days or worsening of symptoms after 5 days suggest development of post-viral ABRS Bacterial Purulent discharge Localized unilateral pain Period of worsening after an initial milder phase of illness

8 ARS Differential Diagnosis ARS Differential Diagnosis Allergic Rhinitis History is important does patient have known allergies? Symptoms exacerbated by allergen exposure? Itchy and watery eyes - common in AR but rare in ARS Uncommon in AR: mucopurulent discharge, pain and anosmia ARS Differential Diagnosis Primary headache syndromes Tension headache Atypical facial pain Migraine Cluster headache Nasal symptoms are frequently absent

9 ARS Differential Diagnosis Dental disease Can present with sinus pain Sometimes there is no toothache or fever Ocular pain syndromes, mainly glaucoma Orofacial pain syndromes (temporomandibular disorder) Chronic fatigue syndrome u Sinonasal Neoplasms Benign Osteoma Papilloma Fibrous Dysplasia Juvenille Nasopharyngeal Angiofibroma Odontogenic neoplasms Malignant Squamous cell carcinoma - #1 Adenocarcinoma - #2 Olfactory Neuroblastoma - rare Mucosal Melanoma - rare Papilloma Exophytic Inverted Image: Pete Batra, MD Inverted: Doug Reh, MD

10 Polyp Juvenille Nasopharyngeal Angiofibroma (JNA) Image by Pete Batra MD Sinus malignancy Ocular Neurologic Trismus Middle Ear effusion g

11 ARS Management ABRS Management: Antibiotics Four recent systematic literature reviews have compared the efficacy of antibiotics to that of placebo for ABRS Antibiotics conferred a small benefit, improving cure rates at 7-15 days from 86% with placebo to 91% with antibiotics Rate of adverse events was higher with antibiotics Decision to treat ultimately comes to down to clinician s experience and patient expectations These prescriptions can be given at the initial visit with instructions on when to fill them, typically if there is no improvement after 7 days or worsening at any time

12 The Microbiome Rich and diverse populations of bacteria live in our nose and sinuses Some microbes may play a beneficial role at the epithelial surface Culture remains clinical standard sometimes helpful Newer genetic techniques show that culture only detects a small percentage of resident bacteria Antibiotics likely create at least some shift of the microbiome from which we hopefully recover More research needs to be done on microbiome disturbance; however, for now the less we disturb the microbiome the better Ramakrishnan VR, Hauser LJ, and Frank DN The sinonasal bacterial microbiome in health and disease. Curr Opin Otolaryngol Head Neck Surg Feb; 24(1): ABRS Management: Antibiotics First Line Amoxicillin, either alone or with clavulanate (when symptoms severe, high risk of pcn resistance, comorbidities present) is the first antibiotic of choice in treating suspected ABRS Second Line (failed 1 st line or allergic) Trimethoprim-sulfamethoxazole, doxycycline, or a respiratory fluoroquinolone Duration = 10 days or fewer Shorter duration favors fewer adverse events and higher patient compliance ARS Management: Intranasal Corticosteroids (INCS) Anti-inflammatory and potential decongestant effects with negligible systemic bioavailability A Cochrane review meta-analysis, which included 1943 participants from four studies concluded: Symptoms in patients receiving INCS, particularly higher dose treatments, were more likely to resolve or improve than in placebo treated patients But the effect is modest, need 100 patients to be treated for seven to have complete symptom relief Aggregate Grade of Evidence: A, Policy Recommendation: strong recommendation

13 ARS MANAGEMENT: ORAL STEROIDS A Cochrane review meta-analysis failed to find significant evidence to support systemic corticosteroids in ARS, despite reviewing trial results from 1193 participants. Policy recommendation Systemic corticosteroids in cases of uncomplicated ARS are not recommended (i.e. no recommendation) Aggregrate grade of evidence: B ARS: Other Treatments Sinus Irrigation (aggregrate evidence: B, Policy Recommendation: Option) Mucolytics, anticholinergics, or herbals (no evidence either way) Decongestants minimal evidence to support their use Antihistamines no evidence to support their use ARS Complications Orbital Cellulitis, abscess, cavernous sinus thrombosis

14 ARS Complications Intracranical Meningitis, abscess, cavernous or sagittal sinus thrombosis, CN Palsy Osseous Osteomyelitis most commonly affecting the frontal bones ( Pott s Puffy Tumor ) Chronic Rhinosinusitis (CRS) Chronic Rhinosinusitis Differential Dx Allergic rhinitis Nonallergic rhinitis GERD Asthma Primary headache disorders Chronic dental infection Foreign body Sinonasal neoplasm CSF rhinorrhea

15 Chronic Rhinosinusitis Workup CT Sinus (cone beam, low dose) Immune workup (CBC, IgA, IgM, IgG, IgE, S pneumo abs, H flu abs) Diagnostic sinonasal endoscopy (polyps, edema, anatomic variations) Allergy test (environmental, food) Chronic Rhinosinusitis Workup CRS Treatment (medical) Intranasal corticosteroids Saline irrigation Oral steroids With polyps yes Without polyps option Oral antibiotics With polyps optional Without polyps yes Aggregate evidence grade - D

16 Macrolide Antibiotics Anti-inflammatory properties Modulate proinflammatory cytokine production Immunomodulatory properties Studies suggest Reduction of nasal fibroblast proliferation, differentiation, collagen production Decreased eosinophilic infiltration into nasal epithelium and lamina propria CRS treatment Procedures Balloon Sinuplasty (in-office) Endoscopic sinus surgery (sometimes in office, usually in OR) Correct anatomic abnormalities (septoplasty, turbinate reduction) Drug eluting spacers (OR for now) Topicals (patients with a prior history of sinus surgery) Antibiotics Surfactants Steroids Other (Manuka honey, xylitol, etc.)

17 Fungal Sinusitis Invasive Fungal Sinusitis Immunocompromised (uncontrolled diabetes, transplant patient, etc) Symptoms Fever, facial or orbital swelling, pain, numbness, unilateral nerve damage, acute visual changes with altered motility or declining vision Emergent referral to ENT/ED Fungus Ball Formerly known as mycetoma, aspergilloma Otherwise healthy patient Surigcal treatment

18 Allergic Fungal Rhinosinusitis Can look ugly on ct scan or MRI Almost always accompanied by polyps Surgical treatment (endoscopic sinus surgery) + po steroids h Pediatric Sinusitis Pediatric Sinusitis History Can often be difficult Information from parent can be subjective Nasal exam (oxymetazoline spray may help) Inferior turbinates, maybe middle turbinates Mucosal character, presence of purulent drainage Oral cavity Purulent postnasal drainage Cobblestoning of the posterior pharyngeal wall Tonsillar hypertrophy

19 Pediatric Sinusitis AAP Guidelines Only symptomatic treatment for children with uncomplicated ARS Antibiotics for severe disease or persistent/worsening course Persistent illness defined as nasal discharge of any quality or cough or both for at least 10 days without evidence of improvement Monitor patients for symptom improvement/resolution within 72 hours of the initial treatment decision Antibiotics Amoxicillin with or without clavulanate recommended for initial empiric treatment of ABRS For amoxicillin allergy, a second or third generation cephalosporin can be used (low risk of cross-reactivity For patients under two years of age with a documented type-1 hypersensitivity to penicillins, a combination of clindamycin and cefixime is suggested A fluoroquinolone, such a levofloxacin, can also be used in patients with a severe penicillin allergy but levofloxacin does not have a US FDA approved indication for ABRS in children and has potentially serious side effects, including tendonitis and tendon rupture Pediatric ARS complications Orbital, intracranial, osseous Signs and symptoms Lethargy, headache Eye pain, pain with eye movement, periorbital edema, diplopia, photophobia, papillary edema High fever, nausea/vomiting, seizures, cranial neuropathies, focal neurologic deficits Workup: CT scan of the sinuses with contrast and/or an MRI with contrast Treatment: IV antibiotics +/- surgery When to refer to ENT? Recurrent sinus infections (>4 per year) Persistent sinus infection (>3 months) Abnormal exam Deviated septum Hypertrophic inferior turbinates Polyps Mass Complication (orbital, intracranial, osseous) Immunocompromised patient

20 Procedures Future Directions Nonsurgical Biologics Drug eluting, self-dissolving spacers Topicals Surgical Fly-through, 3D Navigational Systems More outcomes based research Trend toward in-office treatment (Balloon, navigation, spacers) Take home points Acute Avoid antibiotics if possible Sinus rinse, short course of steroids (40mg qam x 5 days), afrin x 3 days, macrolide unless serious (amox-clav) Chronic or recurrent Allergy CT sinus Daily medical/spray regimen Endoscopy

21 Thank you very much!!