Transcript Cancun Rhinosinusitis 2011

Chronic Rhinosinusitis: What
do we really know?
Jeanette L. Arnold, C-FNP
University of Mississippi Medical Center
Allergy, Immunology & Rheumatology
Consultant for AAFAI have no further disclosures.
[email protected]
Chronic Rhinosinusitis- Objectives:
• Discuss diagnostic criteria for acute and
chronic rhinosinusitis
• Compare and contrast CRS with acute
rhinosinusitis including nasal polyposis
and inflammatory mediators
• Review recent updates on management of
CRS
Diagnosis: What IS Rhinosinusitis?
Rhinosinusitis is:
• An ‘inflammatory process’ involving the
nasal mucosa, mucus membranes of the
paranasal sinuses and/or underlying bone.
• Classified as acute, subacute, recurrent or
chronic based on characteristics including
duration and response to therapy
UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com;
Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A
practice parameter update. JACI 2005; 116: S13-47.
Schematic from UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com.
Sinus CT courtesy of Dr. Scott Stringer, UMC Otolaryngology
UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com
Acute Sinusitis
• Lasts less than 4 weeks
• Usually is of viral origin (98%
likelihood for acute infectious rhinitis)
• Usually self limiting in
immunocompetent persons with
normal anatomy and physiology
• Routine nasophyarngeal cultures not
helpful
Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8. Joint Task Force on
Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI
2005; 116: S13-47. The diagnosis and mangagment of rhinitis: A practice parameter update. JACI
2008; 122: S5.
Subacute Sinusitis
• Protracted episodes lasting 4-12 weeks
• Incomplete resolution of acute episode
• Components of both acute and chronic
sinusitis
Recurrent Sinusitis
• Defined as 3 episodes of sinusitis in 6 months
• Or 4 episodes in 12 months.
Chronic Rhinosinusitis
• Lasts longer than 12 weeks
• May be associated with anatomical
dysfunction,
• Inflammatory process or
• Autoimmune condition
Joint Task Force on Practice Parameters, The diagnosis and management of
sinusitis: A practice parameter update. JACI 2005; 116: S13-47.
Chronic Rhinosinusitis:
• Possible sequelae can include–
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–
–
–
Loss of taste and smell
Development of mucin plugs
Soft tissue displacement
Facial dysmorphism
Bony erosion
• Exacerbation of co-morbidities
Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A
practice parameter update. JACI 2005; 116: S13-47.
Signs & Symptoms include:
– Nasal congestion
– Facial/dental pain
– Cough
– Anosmia
– Headache/body
aches
– Post nasal drip
– Purulent discharge
Adapted from The Diagnosis and Management of Rhinitis:
An Updated Practice Parameter. JACI, August 2008; 122, 2.
Sinusitis in the Common Cold
– Cross sectional study of 197 young adults
with sinus symptoms:
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39% had radiographic evidence of sinusitis on day 7
Symptoms were identical for positive and negative films
Viral infection detected in 81.6% with positive films
No bacterial Ab detected
CRP, Sed rate & WBC low
All patients clinically recovered within 21 days w/o ABIC
Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8.
UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com
Non-infectious Sinusitis: Allergic
and Nonallergic Rhinitis
• IgE mechanisms
• Other causes include:
– hormonal changes
– SE of medications
– Chemical irritants
– Exercise
– Weather and temperature changes
– GERD
• S/S alone do not differentiate
Meltzer, E., Nathan, R., et al., Physician perceptions of the treatment and management
of allergic and nonallergic rhinitis. Allergy & Asthma Proceedings.Jan-Feb 2009: 30 (1): 75-83.
• Rondon, C., Doña, I., et.al. JACI. Evolution of patients
with nonallergic rhinitis supports conversion to allergic
rhinitis. May 2009 (Vol. 123, Issue 5, Pages 1098-1102).
– Roughly ¼ converted from NAR to AR within 3-7 years
– Roughly ¼ developed new co-morbidities w/most common being
asthma
• Jacobs, R., Lieberman, P., et. al. Weather/temperaturesensitive vasomotor rhinitis may be refractory to
intranasal corticosteroid treatment Allergy Asthma Proc.,
March-April 2009 (Vol.30, Num. 2, Pages 120-127)
– Fluticasone INC
– Unexpectedly, found that there was no improvement in any
measure of efficacy.
Meta-Analysis
• Reviewed 1100 articles and 168 abstracts in five
languages. Found 49 studies that were done
well enough to include in their review.
• Used sinus puncture or CT scan as a reference
standard.
• “Clinical Exam is not a reliable method for
diagnosis of acute maxillary sinusitis.”
Varonen J Clin Epid53(9);940-8. 2000 Sept.
Scan Interpretation
• 80% of CT scans are abnormal in viral
rhinosinusitis if obtained within seven days
of the onset of illness.
• 45-50% of asymptomatic individuals will
have findings of mucosal edema on MRI
scanning.
• Films don’t take into account the normal
edema phase of the normal nasal cycle
Gwaltney JM, Philips CO, et al. NEJM 1994:330:25-30; Collins JK Vital Health Statistics
1997; Gordis Rhinology 1997; Patel J. Laryng Otol 1996. Gordis Rhinology 1997.
The problem with radiography is…
• Edema phase of the normal nasal
cycle (unilateral nasal congestion
q 1-4 hours)
• Common cold
• Allergic/vasomotor rhinitis
• Interpretation varies
Collins JK Vital Health Statistics 1997;Gordis Rhinology 1997; Patel J.
Laryng Otol 1996
Evaluate for:
• Allergies- consider skin testing or IgE
assay
• Asthma- consider PFT (pre and post)
• Anatomical obstruction- including nasal
polyposis
– sinus CT +/- rhinoscopy
– mucosal thickening is significant at >6mm in
an adult and >4 mm in a child
– focus on OMC
Chronic sinusitis
• Chronic infectious sinusitis
– usually secondary to primary
immunodeficiencies, cystic fibrosis, or
anatomic defects.
• Non-infectious chronic sinusitis
– thought to be inflammatory disease:
“hyperplastic” or “eosinophilic” sinusitis
Pathogenesis:
Infectious and inflammatory components are likely to
be involved-
Neither one alone explains the disease.
• Infection is often present and may obscure the
underlying inflammatory process.
• Colonization is hard to differentiate from infection.
• Allergy is often present and may alter the
inflammatory response to infection or other
stimuli.
Key distinction:
What is the evidence for distinct pathogenesis?
Chronic rhinosinusitis
(CRS)
CRS without NP
CRS with NP
Clinical
Pathologic
Differences
CRS without NP
CRS with NP
Asthma
Lower
Higher
ASA sensitivity
Lower
Higher
Inflammatory Infilt
Mostly PMN’s
Mostly EOS
Mucus MCP
Mildly increased
Very High
Local IgE prod.
Little/unclear
Lot
Adapted from Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998
Consider:
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GERD
Aspirin hypersensitivity
CF, esp. in children with nasal polyps
Fungal sinusitis
Primary immunodeficiency
– (IgG subclasses not initial labs)
• Motility disorder
• Autoimmune condition
Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis:
A practice parameter update. JACI 2005; 116: S13-47
Link between AR and Asthma is
strong
• Neurologic and inflammatory “crosstalk”
between conditions
• 78% of patients with asthma have AR
• 38% of pt. with AR have concomitant
asthma
• 3-4 fold higher incidence as asthma in AR
than in non allergic children
Meltzer, E., Blaiss, M., et al. Burden of allergic rhinitis: Results from the Pediatric
Allergies in America survey. JACI. Sept. 2009: 124:3: S43-S70.
Summary:
Treatment Options:
• Viral: conservative therapies designed to
promote drainage with comfort measures
and tincture of time including but not
limited to:
– INC, saline nasal lavage
• AR: Avoidance of allergens, patient
education, INC/pharmacotherapy, antiinfectious tx and immunotherapy if
appropriate
Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis:
A practice parameter update. JACI 2005; 116: S13-47.
Bacterial Sinusitis
• Broad spectrum ABIC for 14-21 days
• Maintain drainage
• No benefit for mucolytics or antihistamines
in bacterial sinusitis (??)
• No good data RE use of decongestants
• Some recent studies suggest INC helpful
• Saline mechanically helpful; no clear data
to indicate which method is most helpful
Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis:
A practice parameter update. JACI 2005; 116: S13-47
Above all else, do no harm.
• Do intranasal solutions negatively effect
nasal physiology?
– Infused ofloxacin, betadine, hydrogen peroxide,
amphotericin B, itraconazole, clotrimazole over nasal
respiratory cells
– Noted a strong dose dependant decrease in ciliary
beat frequency.
Gosepath J, et al Am J Rhinol 16(1):25-31 2002
Recalcitrant CRS: investigation and management
Woodbury, Kristin; Ferguson, Berrylin J.
Curr Opin in Otolaryngol Head Neck Surg. 2011 Feb: 19 (1): 1-5
• Literature review commentary vs. meta-analysis
– Long term (@ least 12 wks.) macrolide ABIC- use
supported, esp. in pt. with low or normal IgE
– 1% baby shampoo nasal saline irrigation- no
controlled trials or randomized studies
– Citric acid zwitterionic irrigations destroyed the sinus
cilia (85% were denuded)
– Topical amphotericin B- ineffective
– Mupirocin irrigations- more successful than
vancomycin or ciprofloxin
– Manuka honey irrigations- in vitro study looks
interesting
Take home points:
• Rhinitis of less than 7-10 day duration
typically is less likely to benefit from oral
antibiotics
• Look for presence of nasal polyps to direct
management
• Look for fungus on surgical pathology to
direct care
• Keep those doggies draining (OMC)
JAI-NET: technique for yoga cleansing of the sinuses