9/18/2018. Disclosures. Objectives

Size: px

Start display at page:

Download "9/18/2018. Disclosures. Objectives"

Victor Summers
5 years ago
Views:

The content of this presentation does not relate to any product of a commercial interest.

1 Is It Really Acute Bacterial Rhinosinusitis? Assessment, Differential Diagnosis and Management of Common Sinonasal Symptoms Kristina Haralambides, MS, RN, FNP-C Disclosures The content of this presentation does not relate to any product of a commercial interest. Therefore, there are no relevant financial relationships to disclose. Objectives Understand Sinonasal Anatomy Be able to formulate appropriate differential diagnosis Treatment plan Pharmacologic, both prescription and OTC Non-Pharmacologic Surgical 1

2 Nasal Anatomy Anterior Speculum Exam Endoscopic View Sinus Anatomy Normal Endoscopy Exam Endoscopy of Normal Nasal Cavity 2

3 Normal Endoscopy Exam Patient with a history of endoscopic sinus surgery Insert Video of normal sinus anatomy s/p ess Endoscopy of Sinonasal Cavity in a patient with history of ESS Conventional Criteria for the Diagnosis of Sinusitis Based on the Presence of at Least 2 Major or 1 Major and 2 Minor Symptoms Major Symptoms Purulent anterior nasal discharge Purulent or discolored posterior nasal discharge Nasal congestion or obstruction Facial congestion or fullness Facial pain or pressure Hyposmia or anosmia Fever (for acute sinusitis only) Minor Symptoms Headache Ear pain, pressure, or fullness Halitosis Dental pain Cough Fever (for subacute or chronic sinusitis) Fatigue 8 Lanza and Kennedy Cardinal Criteria for Diagnosis of Acute Rhinosinustitis Nasal Purulence AND Nasal Obstruction or Facial Pressure or Nasal Obstruction and Facial Pressure STATEMENT 1A. DIFFERENTIAL DIAGNOSIS OF ACUTE RHINOSINUSITIS: Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening). Strong recommendation based on diagnostic studies with minor limitations and a preponderance of benefit over harm. 3

Rhinosinusitis Normal Mucosa without Infection Edematous Mucosa with Infection Diagnostic Tools Obtaining a detailed HPI is

4 HPI Symptoms, Time and Severity Allergies Work Environment Family History of CF Asthma NSAID Allergy (Aspirin Exacerbated Respiratory Disease is the triad of Asthma, NSAID allergy and Nasal Polyps) History of GERD Exam Findings with Acute Rhinosinusitis Normal Mucosa without Infection Edematous Mucosa with Infection Diagnostic Tools Obtaining a detailed HPI is key to diagnosing in the nonotolaryngology office setting. Physical Exam with culture of the middle meatus. CT without contrast of the sinuses. 4

5 Endoscopy of Rhinosinusitis Endoscopy of Rhinosinusitis Endoscocpy of Rhinosinusitis In a patient with history of endoscopic sinus surgery Endoscopy of Rhinosinusitis in patient With history of ESS Normal CT Scan of Sinuses 5

6 Treatment Conservative Treatments Surveillance Nasal Saline Irrigation Nasal Steroid Spray 2 sprays twice a day Mucinex 2 tablets twice a day Nasal decongestants FOR NO LONGER THAN 3 DAYS STATEMENT 4. INITIAL MANAGEMENT OF ACUTE BACTERIAL RHINOSINUSITIS (ABRS): Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up, such that antibiotic therapy is started if the patient s condition fails to improve by 7 days after ABRS diagnosis or if it worsens at any time. Recommendation based on systematic reviews of double-blind randomized controlled trials with some heterogeneity in diagnostic criteria and illness severity and a relative balance of benefit and risk. Pharmacological Treatments Antibiotics First line treatment-augmentin 875mg BID for 10 days. PCN Allergic Patients-Doxycycline 100mg BID for 10 days is another good option with low side effect profile. STATEMENT 5. CHOICE OF ANTIBIOTIC FOR ACUTE BACTERIAL RHINOSINUSITIS (ABRS): If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults. Recommendation based on randomized controlled trials with heterogeneity and noninferiority design with a reponderance of benefit over harm. Differential Diagnosis Migraine Other Headache Variant Nasal Polyposis Deviated Nasal Septum Sinonasal Malignancy Chronic Rhinitis Allergic Rhinitis Vasomotor Rhinitis Rhinitis Medicamentosa Drug Induced Extraesophageal Reflux 6

Headache Variant Migraine and cluster headaches often have sinonasal symptoms including: Congestion, rhinorrhea, epiphora Pulsing head pain.

Barometric pressure changes induce symptoms. Sensitivity to activity, light and sound.

7 Headache Variant Migraine and cluster headaches often have sinonasal symptoms including: Congestion, rhinorrhea, epiphora Pulsing head pain. Other characteristics that are suspicious for headache variant versus sinusitis are: Nausea and vomiting. Stable pattern of recurrent headaches. Barometric pressure changes induce symptoms. Sensitivity to activity, light and sound. Remember criteria for sinusitis when a patient complains of sinus headache. Are they having nasal congestion or obstruction, nasal purulence? Allergic Rhinitis Tree Pollen April-May Grass Pollen - May-June Weeds- August-September Nasal Polyposis 7

Deviated Nasal Septum One study reported septal spur or DNS incidence to be as high as 79% in humans. Can cause nasal dryness, nasal congestion and epistaxis.

Know your anatomy. Know your criteria for diagnosis. When a patient fails to meet criteria for diagnosis, remember things that commonly mimic sinusitis.

8 Deviated Nasal Septum One study reported septal spur or DNS incidence to be as high as 79% in humans. Can cause nasal dryness, nasal congestion and epistaxis. Treatment is reducing other edema of the nasal structures versus septoplasty. Summary of Evidenced Based Statements Take Away Listen carefully to HPI as it can often lead you to diagnosis. Know your anatomy. Know your criteria for diagnosis. When a patient fails to meet criteria for diagnosis, remember things that commonly mimic sinusitis. Differential includes, but is not limited to: migraine, headache, allergy, viral illness. Remember that the majority of acute rhinosinusitis cases are viral and a perior of watchful waiting with symptom relief measures is appropriate in the majority of patients. When treatment is indicated, first line treatment is Augmentin or Doxycycline in PCN allergic patients. 8

Questions References Kennedy, D., Hwang,. (2012). Rhinology. Diseases of the Nose, Sinuses, and Skull Base. New York, NY: Thieme Medical Publishers. Patel, Z., Hwang, P. (2018).

9 Questions References Kennedy, D., Hwang,. (2012). Rhinology. Diseases of the Nose, Sinuses, and Skull Base. New York, NY: Thieme Medical Publishers. Patel, Z., Hwang, P. (2018). Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. In S. Bond (Ed.), UpToDate. Retrieved July 10, Patel, Z., Hwang, P. (2018). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. In S. Bond (Ed.), UpToDate. Retrieved July 10, Rosenfeld, R., Piccirillo, J., Chandrasekhar, S.S., Brook, I., Ashok Kumar, K., Kramper, M., Corrigan, M. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology Head and Neck Surgery, Vol. 152(2S) S1 S39. DOI: /

Rhinosinusitis. John Ramey, MD Joseph Russell, MD

Rhinosinusitis. John Ramey, MD Joseph Russell, MD Rhinosinusitis John Ramey, MD Joseph Russell, MD Disclosure Statement RSFH as a continuing medical education provider, accredited by the South Carolina Medical Association, it is the policy of RSFH to