4/5/2011
Current Philosophy and Accurate
Diagnosis of Rhinitis ,URTI and
P
Paranasal
l Sinus
Si
Infection
I f ti
Mark A. Howell M.D., F.A.C.S.
EAR,NOSE and THROAT
ASSOCIATES
Johnson City, Tennessee
Goals
• Review anatomy and physiology of URT
• Review pathophysiology of nasal and
paranasal sinus infections
• Apply current guidelines for accurate
diagnosis of URTI’s
• Apply concepts of appropriate
pharmocologic intervention
WHY?
• Increasing resistance patterns of respiratory
tract pathogens to antibiotics
• Lack of objective clinically useful dx
modalities for URTI’s
• Increasing burden to accurately dx URT
symptoms to differentiate allergic,viral and
bacterial etiologies for appropriate therapy
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4/5/2011
Anatomy
• External Bone and Cartilage
• Internal Bone and Cartilage
• Turbinates
Physiology
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Respiration
Olfaction
Humidification
Filtration
Heat Exchange
Physiology
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Respiratory Epithelium
Mucous Blanket
Blanket-biphasic
biphasic
Cilia
Enzymes
Secretory Antibodies-IgA
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4/5/2011
Nose and Paranasal Sinuses are
anatomically physiologically
related
l t d as single
i l organ system
t
Nasal Symptoms
Rhinitis
Hyperfunction of nose due to various
stimuli, producing rhinorrhea and
nasal obstruction
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Nasal congestion /obstruction
Nasal discharge
Nasal pressure and pain
Alteration olfaction
Itching
Postnasal discharge
Cough/pharyngitis/voice changes
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4/5/2011
Differential Diagnosis of Nasal
and Paranasal Symtoms
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Viral (most common)
Allergic Rhinitis and Nonallergic Rhinitis
Anatomic (septum,turbinates)
Nasal polyposis(Sampters triade,allergic)
Pregnancy(turbinate edema,rhinitis);hypothyroid
Air Pollution and Cigarette
smoking(edema,ciliary damage)
• Decongestant nasal spray,medications(blood
pressure)
• Bacterial(often secondary to above)
Medication and Nasal
Obstruction
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Reserpine
Prazosin
Nadolol
Chloriazepoxideamitryptiline
• Alprazolam(xanax)
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Hydralazine
Propranolol
Thioridizine
Perphenazine
Oral contraceptives
Other Related Factors
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Cystic Fibrosis
Primary and Secondary ciliary dyskinesia
Immune Deficiencies ( HIV)
Hyperreactive respiratory lining (asthma)
Diabetes (insulin dependent,poorly
controlled)
• Facial dysmorphisms;trauma
Rhinitis and Rhinosinusitis
• Sinusitis is usually preceded by rhinitis and
rarely occurs without concurrent rhinitis
• Rhinosinusitis therefore is current term
• Acute
• Subacute
• Recurrent acute
• Chronic
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4/5/2011
Rhinosinusitis
• Acute (up to 4 weeks and total resolution)
• Subacute(4-12 weeks)
• Recurrent Acute(4 or more episodes year
with resolution between attacks)
• Chronic(12 weeks or more of signs and
symptoms)
• Acute exacerbations of chronic
rhinosinusitis
Viral vs. Bacterial ?
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Children 3-8 acute respiratory illness/yr
Adults 3-4 AURTI,s/yr
90% will have CT sinus findings
Only 0.5%-2% positive bacterial cultures
1 billion VURTI expected yearly
20 million ABRS expected
Scope Health Care Problem
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20 million cases/yr
5th most common dx antibiotic rx
9% pediatric rx 2002
21% adult rx 2002
$3.5 billion/year in U.S.A.
Characteristics Viral Infections
• Viral Infection
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Spread person-person contact
Secretions -nose,mouth,eyes
Inhalation-viral-laden
Inhalation
viral laden droplets
Contact-hands,objects
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4/5/2011
Relationship VURTI,s to ABRS
Signs and Sx of VURTI
Rhino and Corona virus no epith.damage
Influenza and Adeno virus damage UR tract
Incites histamine,bradykinin,cytokines(ITL)
histamine bradykinin cytokines(ITL)
Suppress neutrophil, macrophage and
lymphocyte function
• Animal model RSV enhanced H.influenza
infection in URT in cotton rat
• Activation parasympathic and inflammatory
pathways initiate Sx
• Fever,myalgia,pharyngitis
• Nasall congestion,rhinorhea,sneezing,PND
i
hi h
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• Cough,sore throat
• Facial pressure and pain,ear fullness
• Hyposmia/anosmia
• Mucopurulent nasal secretions not specific sign of
bacterial infection(neutriphil influx)
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Similarity Sx VURI’s and ABRS
create significant difficulty
g
g transition of viral
distinguishing
to bacterial infection
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4/5/2011
Xray Dx ABRS?
• Acute URI 87% evidence CT scan
abnormality(Gwaltney 1994)
• Resolution/improvement after 14 days in 79% of
subjects without antibiotic Tx
• URI Sx >10 days or more sinus aspirates
demonstrate bacterial growth 60% samples
Guide Dx ABRS
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Viral URI not resolved 10 days or
URI worsens after 5-7 days and exhibiting
Nasal congestion,drainage,PND
Facial pain/pressure(esp.unilateral or focused;ear
pressure/fullness
Fever,fatigue,cough
Maxillary dental pain
80% preceded VURTI
20% preceded allergic URTI
Diagnostic Modalities
• Unlike OM the sinus cannot readily be examined
as the TM
• Maxillary sinus aspirates accurate/not practical
• Nasal endoscopy allows visualization of middle
meatus and cultures with endoscopic control may
correlate with aspirate but are not complete
• Some studies show 60-85%concordance(small #)
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4/5/2011
Diagnostic Modalities
• Anterior rhinoscopy supportive but not
conclusive
( p tenderness))
• Percussion(tap
• Tranillumination(significant variability in
interpretation)
• Nasal
endoscopy(helpful,expertise,equipment,pt.
cooperation
Imaging
• Plain Xray can evaluate maxillary and
frontal sinuses
p
in 70%
• Concordance with sinus aspirate
• Poor evaluation ethmoid sinus
• Findings A/F level,opacification more
specific
• Mucosal thickening increases senstivity but
decreases specificity
Imaging
• Gold standard for inflammation
• 87% viral URI’s exhibit mucosal thickening
• 30% asymtomatic pt. exhibit abnormal
findings
• Negative plain xray more value than
negative exam
• Findings CT/MRI persist after microbial
resolution up to 8 weeks
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4/5/2011
CDC Position Paper
• Antibiotic Tx moderate severe sinusitis not
improving after 7 days
• Severe sinusitis of any duration(purulent
nasal discharge with high fever,erythema,
swelling,localized pain)
• Clinical judgement
Goals Antibiotic Tx
• Quicker resolution rate
• Return sinuses to health
• Prevent complications(meningitis,brain
complications(meningitis brain
abscess)
• Decrease chronic disease
Selection Antibiotic Therapy
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Limited data bacteriologic studies
Pathogen distribution
p
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PK/PD principals
Mechanisms of antimicrobial resistance
Data in vitro studies
Symptom severity
Incidence spontaneous resolution
Probability of resistant organism
Microbiology ABRS(adult)
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S.pneumoniae 20-40%
H.influenzae 22-35%
M catarrhalis 2-10%
M,catarrhalis
2 10%
Srep spp.3-9%
Anaerobes 0-9%
S.aureus 0-8%
Other 4%
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4/5/2011
Microbiology ABRS (children)
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S.pneumoniae 25-30%
H.influenza 15-20%
M catarrhalis 15-20%
M.catarrhalis
15 20%
S.pyogenes 2-5%
Anaerobes 2-5%
Sterile 20-35%
Nasopharyngeal Flora
• Exchange between lateral wall nose and NP
• Isolates 79% pt. Adenoids and 47% LW
nose
• Molecular typing respiratory pathogens
revealed 89% pt. identical strains both sites
Significance of Nasopharynx
• Colonization respiratory pathogens 70%
children by 12 months age
S.pneumoniae
pneumoniae by 3y/o
• 90% S
• 44% H.influenza 2y/o changing serotypes
1-7 months with production IgA
• 78% M.catarrhalis 2y/o
• Increases winter;URI’s
Nasopharyngeal Flora
• Antibiotic Tx increases resistant strains of
respiratory pathogens(Dagan;PID,’98)
shorter(CID,’97)
97)
• Adults also;duration shorter(CID
• Respiratory pathogens isolated NP of 75%
of adults
• M.catarrhalis resistance with
cephalosporins
• Erythromycin use S.pneumo Finland
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4/5/2011
Mechanisms Resistance
S.pneumoniae
• Alteration PBP at 6 know sites
• Macrolide resistance with alterations
ribosomal bindingg sites;efflux
mechanisms;mutation genes ribosomal
proteins(cross resistance clindamycin)
• Fluroqinolone changes DNA gyrase and
topoisomerase IV;efflux mechanism
• Sulphonamides change binding sites
Prevalence Resistance
H.enfluenza
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Mechanisms of Resistance H.
influenza
• B-lactamase production hydrolyzes amide
bond of B-lactam ring ,inactivating the
antibiotic
• Alteration PBP(BLNAR;PBP3a,3b)
• Efflux pumps(macorlides,azalides )
M.catarrhalis isolates 92% Blactamase producers
30-40% B-lactamase producers
BLNAR strains rare U.S.(Japan)
22% resistant TMP/SMX
PK/PD breakpoints < 3% susceptability to
macrolides;azlides
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4/5/2011
Adjunctive Therapy
Rhinosinusitis
Ajunctive Tx Rhinosinusitis
• Decongestants-systemic(improves nasal
breathing;insomnia may diminish with use)
p
• Topical
decongestants(phenylephrine,oxymetazolin
echildren>6y/oxymetazoline
• Antihistamine-2nd generation avoid anticholinergic drying effects
• Steroids systemic or topical
• Expectorant-guaifenesin needs max dosage
to be effective.
6y/o 600mg/day
• 22-6y/o
• 6-12y/o 1200mg
• 12y/o and >2400mgr
• Robitussin;humibid LA;DeconalsalII;Duratuss-G;Duratuss-GP
Saline Irrigation
Complications of Acute
Rhinosinusitis
• Beneficial as natural approach;pregnancy
and young children with discharge and
mucostasis
• Wash with bulb syringe/nasal aspirator
• OTC sinus rinse
• Orbital-usually acute ethmoid sinusitis
• Preseptal cellulitis-involves eyelid;globe
normal
• Post-septal cellulitis with or without abcess;
involves orbital contents;eyelid
edema;chemosis;proptosis;EOM
impairment;visual changes
• Urgent CT and hospitalization
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4/5/2011
Intracranial Complications
Management Pearls
• Abscess or meningitis
• Usually from acute frontal and/or sphenoid
sinusitis
• More common in adolescents and adults
since younger children have no frontal or
sphenoid sinuses
• Unilateral or isolated “sinusitis” may be
related maxillary dental infection and/or
abscess;nasal foreign body;neoplasm
• Immune compromised pt. As DM,HIV
beware of mucormycosis
• Recurrent rhinosinsitis in children consider
cystic fibrosis ciliary dysfunction;adenoids
• CT and MRI may resolve these dilemmas
Absolute Indications for Surgery
• Rhinosinusitis causing brain
abscess,menigitis;subperiosteal orbital
;
sinus thrombosis;facial
;
abscess;cavernous
cellulitis
• Sinus mucocele or pyocele
• Fungal sinusitis
• Neoplasm or suspected neoplasm
Relative Indications Sinus
Surgery
• Recurrent acute rhinosinusitis with
persistent obstruction of sinus or specific
area of recurringg disease is identified
• Chronic rhinosinusitis failing to clear on
appropriate medical Tx
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4/5/2011
Conclusions
• ABRS may be diagnosed in patients with viral
URI of > 10days or worsens after 5-7 days and is
accompanied by signs and symptoms
• Antimicrobial therapy should cover key
respiratory pathogens
• >30% S.pneumoniae decreased sensitivity to
penicillin
• 30-40% H.flu produce B-lactamase
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4/5/2011
Antibiotic Conclusions
• Per POOLE therapeutic outcome
model,high dose
amoxicillin,cefpodoxime,cefuroxime,cefdin
, p
,
,
ir, and amoxicillin/clav. options for mild
ABRS
• Adult Tx failures/previous antibiotics use
fluoroquinolones,ceftriaxone,or HD
amox/clav
Conclusions (cont’d)
• Pediatric patients ABRS per Poole TX
outcome model – HD amoxicillin/clav. ;
ceftriaxone and amoxcillin/clav. Achieved
>90% clinical predicted efficacy
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