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RHINOLOGY REVIEW part 2

RHINOLOGY REVIEW part 2

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RHINOLOGY REVIEW part 2

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  1. RHINOLOGY REVIEWpart 2 Marilene B. Wang, MD, FACS Professor UCLA Division of Head Neck Surgery Chief of Otolaryngology VA Greater Los Angeles Healthcare System

  2. Sphenoid Sinus Distances • From Anterior Nasal Spine • To Sphenoid Ostium 7 cm • To Pituitary Fossa 8.5 cm

  3. Key Anatomic Landmarks in the Nose and Paranasal Sinuses • Middle turbinate • Lamina papyracea • Ethmoid fovea • Cribriform plate • Sphenoid

  4. Rhinosinusitis-Major factors • Facial pain/pressure • Nasal obstruction/blockage • Nasal discharge/purulence/discolored postnasal drip

  5. Rhinosinusitis-Major factors • Hyposmia/anosmia • Purulence in nasal cavity on examination • Fever (acute rhinosinusitis only)

  6. Rhinosinusitis-Minor factors • Headache • Fever • Halitosis • Fatigue

  7. Rhinosinusitis-Minor factors • Dental pain • Cough • Ear pain/pressure/fullness

  8. Categories of Rhinosinusitis • Acute • Subacute • Chronic • Recurrent, acute • Acute exacerbations of chronic

  9. Acute Rhinosinusitis • Duration up to 4 weeks • > 2 major factors • 1 major factor + 2 minor factors • Nasal purulence on exam

  10. SubacuteRhinosinusitis • Duration 4-12 weeks • >2 major factors • 1 major factor + 2 minor factors, or nasal purulence on exam • Complete resolution after effective medical therapy

  11. Chronic Rhinosinusitis • Duration > 12 weeks • History same as for subacute • Facial pain does not constitute suggestive history in absence of other nasal symptoms or signs

  12. Recurrent acute • >4 episodes/year + each episode last >7-10 days. • Absence of intervening signs of chronic rhinosinusitis

  13. Acute exacerbations of chronic • Sudden worsening of chronic rhinosinusitis • Return to baseline after treatment

  14. Factors Associated with Chronic Rhinosinusitis • Allergies • Immunodeficiency • Genetic/congenital

  15. Factors Associated with Chronic Rhinosinusitis • Endocrine • Neuromechanism

  16. Factors Associated with Chronic Rhinosinusitis • Anatomic • Neoplastic • Acquired mucociliary dysfunction

  17. Associated Factors • Microorganisms—viral, bacterial, fungal • Noxious chemicals, pollutants, smoke • Medications • Trauma • Surgery

  18. Microbiology of acute sinusitis (adults) • S. pneum (20-43%) • H. influenzae (22-35%) • Strep spp. (3-9%) • Anaerobes (0-9%) • M. catarrhalis (2-10%) • S. aureus (0-8%) • Other (4%)

  19. Microbiology of acute sinusitis (children) • S. pneum (25-30%) • H. influenzae (15-20%) • M. catarrhalis (15-20%) • S. pyogenes (2-5%) • Anaerobes (2-5%) • Sterile (20-35%)

  20. Recommended abx for adults with acute bacterial rhinosinusitis • Mild disease with no recent antimicrobial use • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef

  21. Switch if no improvement after 72 hours • Tequin, Levaquin, Avelox • Augmentin • Combination (Amox or clinda + Suprax)

  22. Abx for acute sinusitis if PCN-allergic • Bactrim • Doxycycline • Zithromax, Biaxin, Erythromycin • Switch to quinolone if no improvement in 72 hours

  23. If recent abx use • Quinolone • Augmentin • Clindamcin + rifampin • Consider IV abx

  24. Abx for acute sinusitis in children • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef • Switch if no improvement after 72 hours

  25. If PCN-allergic • Bactrim • Macrolide

  26. If recent abx use (children) • Augmentin • Rocephin • Bactrim, macrolide • Consider IV abx if no improvement

  27. Other symptomatic therapies • Afrin for 3 days • Normal saline sprays • Decongestants • Antihistamines • ?Steroids

  28. Complications of sinusitis • Periorbital cellulitis • Preseptal cellulitis/abscess • Orbital cellulitis • Orbital abscess • Cavernous sinus thrombosis

  29. Allergic Rhinitis • Widespread affliction—the most common allergic disease • Affects 10-30% of American adults— • >20 million people, adults and children • Results in missed work and school days, poor quality of life

  30. Symptoms of allergic rhinitis • Allergic salute • Shiners • Itchy, red conjunctiva • Sneezing • Post-nasal drip, rhinorrhea, congestion

  31. Common allergens--indoor • Dust • Mold, mildew • Plants • Animal dander • Feathers/down

  32. Common allergens--outdoor • Pollen • Smog • Trees, grasses, weeds • Dust, fertilizer, chemicals

  33. Associated diseases • Asthma • Allergic fungal sinusitis • Cystic fibrosis • Mucociliary dysfunction • Connective tissue disorders (Wegener’s granulomatosis, sarcoid)

  34. Associated diseases • Nasal polyposis • Samter’s triad (aspirin sensitivity, nasal polyps, asthma) • Cocaine use

  35. Chronic rhinosinusitis • Antibiotics • Antihistamines • Nasal steroids • Normal saline irrigations • Allergy evaluation +/- immunotherapy

  36. Chronic rhinosinusitis • Sinus CT scan • Consider anatomic factors—septal deviation, nasal polyps, concha bullosa, ostio-meatal blockage

  37. Indications for sinus surgery • Nasal polyposis • Anatomic blockage—deviated septum, enlarged turbinate, concha bullosa • Mucocele • Orbital abscess

  38. Indications for sinus surgery • Fungal sinusitis—allergic vs. invasive (mucor) • Tumor of nasal cavity or sinus

  39. Indications for sinus surgery • Chronic, recurrent sinusitis • Failure to respond to maximal medical therapy • Obtain cultures

  40. Surgical Complications—common, minor • Nasal congestion • Headache/sinus pain • Fatigue • Prolonged bleeding/crusting

  41. Complications—major, rare • Breach of lamina papyracea—damage to extraocular muscles, periorbital ecchymoses • Damage to optic nerve—blindness • Breach of cribriform—CSF leak • Meningitis

  42. Long-term management • May be a lifelong disease • Allergy control—antiihistamines, nasal steroids, immunotherapy • Oral steroids—judiciously • Antibiotics for acute exacerbations

  43. Long-term management • Environmental control—avoid carpet, damp, mold, older homes, smog • Saline irrigations

  44. Long-term management • Alternative therapies—acupuncture, stress management, herbal remedies • Pain management • Multi-disciplinary effort—work with allergy, infectious disease, neurology/pain management services

  45. Allergy Review • 4 types of allergic reactions (Gell and Coombs) • Type 1 – IgE • Type 2 - IgG--antigen • Type 3 – Immune complex • Type 4 – Delayed hypersensitivity

  46. Type 1 • Mast cells bind IgE via their Fc(ε) receptors • Mast cell degranulates and releases mediators--produce allergic reactions • Hypersensitivity usually appears on repeated contact with the allergen. • Examples of type I allergic reactions • Anaphylaxis, atopic asthma, atopic eczema, drug allergy, hay fever

  47. Type 2 • Antibody (IgG or IgM) directed against antigen on an individual's own cells, or against foreign antibody (after blood transfusion) • Cytotoxic action by killer cells, or to lysis mediated by the complement system. • Autoimmune hemolytic anemia, Goodpasture's syndrome, hemolytic disese of the newborn, myasthenia gravis, pemphigus

  48. Type 3 • Immune complexes (antigen and usually IgG or IgM) deposited in the tissue • Complement is activated and polymorphonuclear cells are attracted, causing local tissue damage and inflammation. • Polyarteritis nodosa, post-streptococcal glomerulonephritis , systemic lupus erythematosus