Acute Chronic Sinusitis

1. Acute & Chronic Sinusitis ?????? ????

2. ????????? ??? ?????? ??????? ??? ??????????? ?????? ?????. ????????? ????? 9% ???? ?????? ?????? ??????????? ?-21% ????????. ??? ?????? ?-2002 ????"???? ?????? ?-2002 ????"?

3. Rhinosinusitis Acute rhinosinusitis Subacute rhinosinusitis Chronic rhinosinusitis Recurrent ARS Acute rhinosinusitis superimposed on CRS ????? ?? ????????????? ??? ??????, ?????? ????? ?? ????????????? ??? ??????, ??????

4. Acute rhinosinusitis Acute sinusitis 7-21 days (7 days viral illness) Spontaneous resolution of ARS -40% The most common pathogens: strep pneumonia-30%, non typeabale hemophilus infl.-20%, moraxella catarrhalis.(20% in children) Staph aureus- 30% Anaerobes- rare ?????? ??? ????? ???? ?? 30 ??? ?????? ??? ????? ???? ?? 30 ???

5. Recurrent ARS Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic. RECURRENT ARS ???? ??? ?? ????????? ????? ?????? ?? 30 ??? ?? ????? ?????? ??? ????? ??? ??????? ???? ????? 10 ????. ???? ???? ??? ?? ????? ??????????. RECURRENT ARS ???? ??? ?? ????????? ????? ?????? ?? 30 ??? ?? ????? ?????? ??? ????? ??? ??????? ???? ????? 10 ????. ???? ???? ??? ?? ????? ??????????.

6. Subacute sinusitis Subacute RS:3W-3months The same pathogens as in ARS ?????? ????? ????? ???? ??? 30-9- ??? . ?????? ????? ????? ???? ??? 30-9- ??? .

7. Chronic rhinosinusitis Beyond 3 months Bacteria are as in ARS, but More non-typeable H Influezae More staph aureus, anaerobic bacteria, gram- Negative, pseudomonase aeruginosa Polymicrobials with resistant organism Culture recommended ????? ??????? ?? ???????? ??? ???????? ??????? ???? ?? ???? ????? ?? ??????? ????? ??????? ??????. ?????? ????? ?????? ?????? ???. ????? ??????? ?? ???????? ??? ???????? ??????? ???? ?? ???? ????? ?? ??????? ????? ??????? ??????. ?????? ????? ?????? ?????? ???.

8. Acute bacterial sinusitis superimposed on chronic sinusitis Patients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not.

9. Major & Minor signs and symptoms in diagnosis of Chronic RS Majors: Facial pain/pressure Nasal congestion/fullness N. obstruction/blockage N. discharge/purulence Hyposmia/ anosmia Purulent rhinitis Fever (acute sinusitis only) Minors: Headache Fever Halitosis Fatigue Dental pain Cough Ear pain/ pressure/fulln

10. Clinical Diagnosis of rhinosinusitis 2 or more major factors 1 major & 2 minor factors Or Purulence on examination Duration of symptoms > 10 days or worsen after 5-7 days

11. Predisposing factors URI Allergy Trauma Dental infection Environmental Pollutants GERD Cystic Fibrosis

12. � Facial pain on percussion or palpation, sedimentation rate and white blood count have little diagnostic value.� ?????? ????? ???? ??????????: ?????? ????? DOUBLE SICKNENING ????????? ??????? ??????? ???? ???????????????? ????? ???? ??????????: ?????? ????? DOUBLE SICKNENING ????????? ??????? ??????? ???? ??????????

13. The gold standard for the diagnosis of acute bacterial sinusitis is the recovery of bacteria in high density (>10 colony-forming units/mL) from the cavity of a paranasal sinus

14. Rhinosinusitis definitions for patient care ????? ?CRS ?? ????? ??? ????? ???? ????? ?CRS ?? ????? ??? ????? ????

15. ?-AFRS ??????? ???????????? ??? IgE ?????? ????? ?? ?? ??????? ?????? ???? ????? ??? ?? ????? ??? ???? ???? ??????. ?-AFRS ??????? ???????????? ??? IgE ?????? ????? ?? ?? ??????? ?????? ???? ????? ??? ?? ????? ??? ???? ???? ??????.

16. Dose the patient have 2 or more major factors ...? Yes: Amoxicillin Or Bactrim No: Treat symptomatically Saline irrigation Oral decongestant Antihistamine (allergy) Reevaluate in 10 days

18. Severe sinusitis with suspected orbital or intracranial complications �cefuroxime or ceftriaxone The best in crs treat according to culture For crs treat 3 weeks, while improvement within 3-5 days 3-6 weeks prophylaxis once daily therapy for patients with rapid recurrence??

19. Antimicrobial treatment guidelines 1. mild symptoms, not received antibiotics within 4-6w. 2. mild disease, who received antibiotics within 4-6w, or with moderate disease regardless of recent antibiotic exposure, ? guidelines ???? ?? ?????? ?? ????????? ???? ????????: ?????? ????? ?????? ????? ??????? ???????? ??? ?????? ??????. ??? ?? ???? ????? ?????? ??? 72 ???? ???? ????????? guidelines ???? ?? ?????? ?? ????????? ???? ????????: ?????? ????? ?????? ????? ??????? ???????? ??? ?????? ??????. ??? ?? ???? ????? ?????? ??? 72 ???? ???? ????????

20. ???? ?????? ??????????: ???? ?? ???????? ???? ?? ?????? ??? ?????? ?? ???????? ???????? ???? ?? ????? ????? ????? ????? ???? ???????? ????? ??????? ????, ??? ?????????. ????? ??????? ???? ??????

21. ????? ???????? ???????????? ???????? ??????? ??????? ????? ? 90-92% ????: fluoroquinolones ??? levofloxacin ?- moxifloxacin. ceftriaxone ,augmentin ?????? ?? 83-88%: cefixime high dose amoxicillin, cefpodoxime proxile, cefuroxime axetil, cefdinir TMP/SMX ?????? ?? 77-81%:docxycyline, clindamycin, azitromycin, clarithromycin, erythromycin ?????? ?? 65-66%: cefaclor,loracarbef ??????????? ?????? ????- 4gr/day Cefixime ???? ???????? ?????????? ???????? ???? ?????? ??????? ?????? ?? ????? ?????? ?? ARS ???? 62% ??????????? ?????? ????- 4gr/day Cefixime ???? ???????? ?????????? ???????? ???? ?????? ??????? ?????? ?? ????? ?????? ?? ARS ???? 62%

22. ????? ?????? 91-92% : ceftriaxone, augmentin 82-87%: amoxicillin, cefpodoxime proxetil, cefixime, cefuroxime axetil,cefdinir,TMP/SMX 78-80%: clindamycin, cefprozil, azithromycin, clarithromycin, erythromycin 67-68% : cefaclor ???????? ?????? ???? ?? 90mg/k/day ??????? 45mg/k/day ???? ?????? ?? ARS ?????? ???????? ???? 63% ???????? ?????? ???? ?? 90mg/k/day ??????? 45mg/k/day ???? ?????? ?? ARS ?????? ???????? ???? 63%

23. ??????? ?????? ?????? ???????? ?? ???? ??? Augmentin, amoxicillin, cefpodoxime proxetil, cefuroxime axetil, or cefdinir For b-lactam allergies patients: TMP/SMX, doxycilline, azithromycin, clarithromycin,erythromycin Failure after 72h: reevaluation or switch to alternate antimicrobial therapy

24. ?????? ?????? ?????? ???????? ?? ???? ??? ?????? ???? Respiratory flouroquinolones, augmentin (4g/day),ceftriaxone (1-2 g/day 5 days), combination of g+ and g- Failure after 72h: switch to alternate antimicrobial therapy, or reevaluation CT scan, endoscopy, sinus aspiration and culture ?????? ?4-6 ??????? ???????? ???????????? ?? ??????? ?? ???? ??????? Respiratory quinolones :gatifloxacin, levofloxacin,moxifloxacin ????? ?????? ??? ????? ???? ?????: ??????????? ?????? ???? ?? ?????????? ???????? ?? ??????????? ?????? ???? ??????????? ????????. ?? ?????? ???????? ?? ???? ?????? ????? ??? ???? ??? ???? ?-10-14 ??? ??? ????? ???????? ???????. ??? ?? ?? ????? ?????????? ??????? ????? ?????? ???????? ????? ????? ?? ????? ?????? ???? ????? ???? ??? ???? ?????????????????? ?4-6 ??????? ???????? ???????????? ?? ??????? ?? ???? ??????? Respiratory quinolones :gatifloxacin, levofloxacin,moxifloxacin ????? ?????? ??? ????? ???? ?????: ??????????? ?????? ???? ?? ?????????? ???????? ?? ??????????? ?????? ???? ??????????? ????????. ?? ?????? ???????? ?? ???? ?????? ????? ??? ???? ??? ???? ?-10-14 ??? ??? ????? ???????? ???????. ??? ?? ?? ????? ?????????? ??????? ????? ?????? ???????? ????? ????? ?? ????? ?????? ???? ????? ???? ??? ???? ????????????

25. ?????? ?????? ?????? ?????? ?? ???? ??? Augmentin (90mg/k/day), amocixillin (90 mg/k/day), cefpodoxime proxetil, cefuroxime axetil, or cefdinir Type I hypersensitivity to b-lactams patients: TMP/SMX, azithromycin, clarithromycin or erythromycin. Make differentiate an immediate hypersensitivity from other side effects Failure after 72 h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

26. ?????? ?????? ?????? ?? ???? ??? (????? ???????) ?? ???? ??????? Augmentin(90mg/k/day), cefpodoxime proxetil, cefuroxime axetil or cefdinir. Beta lactams allergic patients: TMP/SMX, azithromycin, clarithromycin, erythromycin Clindamycin for s pneumoniae Ceftriaxone (5 days, parenteral), or combination therapy for G+ and G- Clindamycin or amocixillin and cefixime Clindamycin or amoxicillin and rifampin ????? ?????? ?-4-6 ?????? ???????? ????????????. ????? ?????? ?-4-6 ?????? ???????? ????????????.

27. New insights into the role of bacteria in CRS Bacterial superantigens-exotoxins that are able to activate T lymphocytes Pathogenesis of nasal polyposis- superantigens from S aureus ????????????? ??????? ???????????? ????? ??? ??????? ?? ???????? ??????? 30% ?T ????????? ?????? ????????? ????????, ??? ??????? ???? ?-0.01% ??-T ?????????. ??? ?? ????????????? ?????? ????? ????????? ??????, ?????? ?????? ??????? ???? ????????????, ???? ????? ??????? ?? IGE ????????????? ??????? ???????????? ????? ??? ??????? ?? ???????? ??????? 30% ?T ????????? ?????? ????????? ????????, ??? ??????? ???? ?-0.01% ??-T ?????????. ??? ?? ????????????? ?????? ????? ????????? ??????, ?????? ?????? ??????? ???? ????????????, ???? ????? ??????? ?? IGE

28. Biofilms-a artificial or damaged biologic surface that formed communicating organization of microorganisms surrounded by a glycocalys Biofilms is relatively impervious to antibiotics and is never eradicated Mechanical debridement- the only way to resolve biofilms ??????????? ????? ???????? ???? ?????? ????? ???????? ????? ?? HOST ????????? ????????????????. ???????? ????? ????? ???? ?? ????? ??????? ???? ?????? ?CRS , ??? ?????? ?????? ??? ????? ?? ????? ?? ?????? ?????? ???????, ????? ????????? ??? ????? ????????? ??????? ?? ????? ?????? ??????????. ????? ????????? ???? ?????? ????????? ???????? ?????? ???? ????? ????? , ??? ????? ?????? ???? ?????? ?? ???? ????? ????????? ???????? ?????? . ??????????? ????? ???????? ???? ?????? ????? ???????? ????? ?? HOST ????????? ????????????????. ???????? ????? ????? ???? ?? ????? ??????? ???? ?????? ?CRS , ??? ?????? ?????? ??? ????? ?? ????? ?? ?????? ?????? ???????, ????? ????????? ??? ????? ????????? ??????? ?? ????? ?????? ??????????. ????? ????????? ???? ?????? ????????? ???????? ?????? ???? ????? ????? , ??? ????? ?????? ???? ?????? ?? ???? ????? ????????? ???????? ?????? .

29. Osteitis: the role of the bone Osteomyelitis can be seen at a distance from the primary infection Inflammatory bone changes were noted on contralateral side in 52% of the animals The changes in the involved bone can explain why CRS is relatively resistant to medical therapy. ?? ?? ?? ???? ??????? ???? ?? ????? ?? CRS . ????? ????????????????? ??? ????? ???????. ?? ?? ?? ???? ??????? ???? ?? ????? ?? CRS . ????? ????????????????? ??? ????? ???????.

30. Failed CRS To sinus surgery or systemic steroid/antibiotics Macrolid therapy (long term, low dose) effective ????? ?????? ?????????? ?????? ??????. ????? ?????? ????? ?? ????? ???? ?? ????? ????? ????? ????? ??????????? ?? ?????????? ?? ??????? NO ?????.????? ?????? ?????????? ?????? ??????. ????? ?????? ????? ?? ????? ???? ?? ????? ????? ????? ????? ??????????? ?? ?????????? ?? ??????? NO ?????.

31. CRS 78 had criteria to CRS 37- CT findings: positive 41- CT findings: negative 35: endoscopy negative & CT negative 20: endoscopy negative & CT positive 55: endoscopy negative ?-78 ??? ????????? ??????? ???????? ?????????? ??????. ????? ????? ???? ???????????? ????? ???. ?? ?????? ???? ?? ??????? ?????? ?? ????? ?? ??????? ????, ???? ??????? ?? ????. ?-78 ??? ????????? ??????? ???????? ?????????? ??????. ????? ????? ???? ???????????? ????? ???. ?? ?????? ???? ?? ??????? ?????? ?? ????? ?? ??????? ????, ???? ??????? ?? ????.

32. Radiology & clinical exam Correlated with a Sensitivity of 75% And specificity of 84% Endoscopy correlated poorly with sinus disease and not predictive ????? ???????: ???? ????? ?? ???? ???????, ??????? ?? ????? ????? ??????????? ???? ????? ???? ?? ????????? ????? . ??? ?? ?? ?????????? ???? ?????? , ??? ???? ?????. ????? ???????: ???? ????? ?? ???? ???????, ??????? ?? ????? ????? ??????????? ???? ????? ???? ?? ????????? ????? . ??? ?? ?? ?????????? ???? ?????? , ??? ???? ?????.

34. Endoscopy/ct findings/clinical Easy to diagnose CRS by endoscopy alone when nasal polyps, purulence, or fungus is observed, when absent, establishing the diagnosis may be more difficult 45% of patients with clinical CRS were both endoscopically and radiographically negative. Stankiewicz and Chow. Otolaryngol head neck surg 2002

35. Endoscopy/ct findings/clinical Negative endoscopy alone is insufficient to rule out sinusitis. 26% of patients who were negative on endoscopy had positive CT � this would suggest that if endoscopy is negative most of the time the ct will be also negative, even with a positive history.

36. ?????? ?????? ?????? ?????? (?????? URI) ????? ???? ???? ?? ????? ????? ??? 10 ???? ????? ???? ?????? ???????? ?? ????????? ?? VIRAL URI ??? ?????? ???? 10 ???? ?? ?????? ???? 5-7 ????. The diagnosis of acute bacterial sinusitis is based on clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe

37. ?????? Persistent symptoms are those that last longer than 10 to 14, but less than 30, days. Such symptoms include nasal or postnasal discharge (of any quality), daytime cough (which may be worse at night), or both.

38. ?????? Severe symptoms include a temperature of at least 102�F (39oC) and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill. The child who seems toxic should be hospitalized and is not considered in this algorithm.

39. children ??????? ???????? ?????? ????? ????: ?????????? ????????? ?????? ??????. ???????? ???? 5 ????????? ????? ??????? 7-8 ????. ????? ?? ??? 1 ??? ?????? ???? ??????? ???? ???? ????? ??????? ?guide LINES -??????? ???????? ?????? ????? ????: ?????????? ????????? ?????? ??????. ???????? ???? 5 ????????? ????? ??????? 7-8 ????. ????? ?? ??? 1 ??? ?????? ???? ??????? ???? ???? ????? ??????? ?guide LINES -

40. ARS in children Diagnosis in children based on clinical criteria Radiology is only for complications, persistent or recurrent sinusitis For prevention there is no prophylactic antimicrobial treatment, ancillary therapies, complementary/alternative medicine ??????????? ?????? ???? ????????? ??????? ??????? ?? ???? ?? ???? ????? ?????????????????? ?????? ???? ????????? ??????? ??????? ?? ???? ?? ???? ????? ???????

41. Surgical management of crs in children 5-8 events of colds/year 5%-13% will complicate by acute RS Most of children with RS respond to medical treatment Today surgery consist of sinus lavage, ESS, adenoidectomy

42. Goal of surgery Surgery is for control of symptoms, better quality of life and to prevent complications Indications to surgery are not uniform between OL and P �cure�-the goal for surgery, but is not the likely end point Reversible mucosal disease may be possible in the long run, but is unlikely to be realized in the short term

44. Maximal medical management Reflux Macrolids Antileukotriens Irrigations-nasal sprays Alternative medical approaches In few children with �end-stage� CRS, I have personally seen much improvement with aggressive medical management of reflux. Could it be that earlier treatment may prevent the long-term mucosal inflammation that is not easily reversed? macrolides have both antimicrobial and antiinflammatory properties If one believes that CRS is a result of obstruction of mucous flow, it seems logical that decreasing the local inflammation could be helpful in reducing edema and improving mucous flow. the use of antileukotrienes has seemed to be effective in reducing the allergic cascade, decreasing the symptoms of allergy [11��]. Saline lavage should debride the nasal cavity of the thick mucous and crusts. It could be effective in delivery of medicines, Nebulized antibiotics seemed to give longer infection-free periods than standard therapy[13] The bulb syringe was statistically superior to the nebulizer in all sinus sites and to all alternative delivery systems in the ethmoid There are few well-controlled studies with these agents, alternative medical approaches, and of course even fewer for children with CRS. In few children with �end-stage� CRS, I have personally seen much improvement with aggressive medical management of reflux. Could it be that earlier treatment may prevent the long-term mucosal inflammation that is not easily reversed? macrolides have both antimicrobial and antiinflammatory properties If one believes that CRS is a result of obstruction of mucous flow, it seems logical that decreasing the local inflammation could be helpful in reducing edema and improving mucous flow. the use of antileukotrienes has seemed to be effective in reducing the allergic cascade, decreasing the symptoms of allergy [11��]. Saline lavage should debride the nasal cavity of the thick mucous and crusts. It could be effective in delivery of medicines, Nebulized antibiotics seemed to give longer infection-free periods than standard therapy[13] The bulb syringe was statistically superior to the nebulizer in all sinus sites and to all alternative delivery systems in the ethmoid There are few well-controlled studies with these agents, alternative medical approaches, and of course even fewer for children with CRS.

45. Surgical management children Biomaterials Subperiosteal abscess Older children seemed to do better than younger children in general. If the child was older than 6 years, there was an 89% success rate, but the success rate was only 73% in those younger than 6 years. The few children who were operated who were younger than 3 years of age had a 75% chance of needing additional surgery �Cure,� although the goal for surgery, is not the likely end point. Our hope of reversible mucosal disease may be possible in the long run, but is unlikely to be realized in the short term. Hyaluronic acid would seem to fit that bill. Merogel was invented for that reason Older children seemed to do better than younger children in general. If the child was older than 6 years, there was an 89% success rate, but the success rate was only 73% in those younger than 6 years. The few children who were operated who were younger than 3 years of age had a 75% chance of needing additional surgery �Cure,� although the goal for surgery, is not the likely end point. Our hope of reversible mucosal disease may be possible in the long run, but is unlikely to be realized in the short term. Hyaluronic acid would seem to fit that bill. Merogel was invented for that reason

46. The surgical site in children There is strong evidence to support the fact that the OMC area is the primary site of involvement of inflammatory sinuses disease.

48. Surgical management in children Role of adenoidectomy: 1. reservoir for pathogenic bacteria 2. interfere with nasal mucociliary clearance 3.better drainage Overall success of adenoidectomy-50% Studies show reduction in the number of bacterial pathogens in the nasopharynx after adenoidectomy

49. Fear of surgery? Surgery may cause growth retardation of the midface Bothwell et al. showed no difference in facial growth of children with CRS who operated compare with children who refused surgery.

50. Surgery Children who fail medical therapy benefit from surgery Adenoidectomy recommended initially for children 6 years of age (no asthma, low CT score) ESS and adenoidectomy for children older than 6 (asthma and high CT score) Ramadan. Laryngoscope.2004

51. Results of surgery children Older children do better than youngest Old children (>6 y/o)- successes rate is 89% , but younger children (<6 y/o)- successes rate is only 73% >3 y/o who were operated have 75% chance to be reoperate

52. Antibiotic therapy Amoxicillin -1st choice In children give high dose 60mg/kg/day To consider 2nd generation cephalosporin, or erythromycin with sulfonamide ,or high dose penicillin in areas with a high incidence of bacterial antibiotic resistance. Based on studies showing a 20% incidence of viable bacteria through maxillary sinus tap after 7 days of antibiotic therapy, most authors recommend 10 days of therapy in the manage of acute sinusitis ????? 40 ?? ????? ????. ????? 40 ?? ????? ????.