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New definition and classification Update on literature and treatments

Acute Rhinosinusitis – bacterial infection or inflammation?  Prof. Dr. Philippe Gevaert Dienst Neus-, keel- en oorheelkunde Allergienetwerk UZ-Gent. New definition and classification Update on literature and treatments New and practical treatment schemes acute rhinosinusitis adults

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New definition and classification Update on literature and treatments

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  1. Acute Rhinosinusitis – bacterial infection or inflammation?  Prof. Dr. Philippe GevaertDienst Neus-, keel- en oorheelkundeAllergienetwerk UZ-Gent

  2. New definition and classification • Update on literature and treatments • New and practical treatment schemes • acute rhinosinusitis adults • children • chronic rhinosinusitis adults • children • nasal polyposis • Research needs and priorities

  3. Definitions and classification for General Practice • Based on symptoms: • Two or more symptoms, one of which should be either • nasal blockage/obstruction/congestion or • nasal discharge: anterior/post nasal drip; • ± facial pain/pressure, • ± reduction or loss of smell • Examination: anterior rhinoscopy • X-ray/CT not recommended • * DURATION • ACUTE / intermittent < 12 weeks • complete resolution of symptoms • CHRONIC / persistent > 12 weeks • incomplete resolution of symptoms • Special attention to questions on allergic symptoms

  4. Definitions and classification • Based on symptoms: • Two or more symptoms, one of which should be either • nasal blockage/obstruction/congestion or • nasal discharge: anterior/post nasal drip; • ± facial pain/pressure, • ± reduction or loss of smell • AND EITHER • endoscopic findingsof polyps • mucopurulent discharge • edema or obstruction • OR • CT scan abnormality: mucosal changes • within ostiomeatal complex or sinus cavity

  5. Definitions and classification CLASSIFICATION OF RHINOSINUSITIS * SEVERITY Visual Analogue Scale (VAS) mild 0-3 moderate 3-7 severe 7-10 * DURATION ACUTE / intermittent < 12 weeks complete resolution of symptoms CHRONIC / persistent > 12 weeks incomplete resolution of symptoms

  6. Headache/facial pressure in sinusitis

  7. Nasal Endoscopy

  8. Imaging of sinsuses • RX sinuses: - Waters, Caldwell an Hirtz • - poor sensitivity and specificity • - NOT RECOMMENDED!

  9. Imaging of sinsuses • MRI: only recommended in tumor diagnosis • CT sinuses: current standard imaging (50mGy) • Cave! radiation damage of lens (500-2000mGy) • - Acute rhinosinusitis: only if signs for complications!! • Chronic sinusitis: only after 4w-12w treatment!

  10. Anatomy and physiology COMMON COLD BACTERIAL SUPERINFECTION Strep pneu / Haemo infl / Morax catar increasing symptoms after 5 DAYS no resolution after 10 DAYS ACUTE rhinosinusitis MULTIFACTORIAL ETIOLOGY CHRONIC rhinosinusitis EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601

  11. < 4 years 5-10 years Adolescents Young adults rhinovirus parainfl. rhinovirus rhinovirus RSV adenovirus influenza echovirus parainfl. enterovirus echovirus influenza adenovirus RSV coronavirus coxsackie influenza rhinovirus RSV coronavirus influenza parainfl. RSV adenovirus parainfl. adenovirus Kirkpatrick, 1996 Viruses in acute rhinitis and rhinosinusitis Adults Most common rhinovirus influenza echovirus coxsakie coronavirus RSV parainfl. Least common adenovirus

  12. Pathophysiology Viral Rhinitis Impact of viral infection on the mucosa • Epithelial changes • Hypersecretion and oedema •  Goblet cells (hypersecretion),  ciliated cells (secretion stasis) • Cell destruction with vasodilatation (cavernous sinuses!) • Release inflammatory mediators from inflammatory cells • Seromucous hypersecretion and exudation  Thickening lamina propria

  13. Symptoms Viral Rhinitis • Quickly passing sore throat: viral pharyngitis, swollen throat • Nasal symptoms: congestion, sneezing, rhinorrhea  gone after 7 d, mucus production peaks on d 3 and 4 • Coughing: longest lasting symptom,  weeks in smokersand patients with reflux! • 1/10: short headache • Rarely tremors, general malaise • Note: more serious problems with anatomical anomalies (deviated septum) or children: otitis, rhinopharyngitis, sinusitis, tracheitis, bronchitis

  14. Symptoms Viral Rhinitis

  15. Cough after Viral Rhinitis (smoking)

  16. Complications after Viral Rhinitis

  17. Therapeutical Options Common Cold • Nothing • Local vasoconstrictors: preferably only at night, not > 7d • Physiological flushing: mainly with children or with anatomical anomalies • Note: other types of rhinitis where physiological flushing -possibly supplemented with ointment application- may be useful: occupational rhinitis, rhinitis due to irritants, atrophic rhinitis • Antibiotics: useless, unless complication due to surinfection

  18. Common cold induces changes in sinus mucosa Virus ICAM-1 CD8+ T cytotxic cells CD8+ CTLs b b a a IL IL - - 1 1 , , IL IL - - 6 6 , , TNF TNF - - Natural Killer cells NKcells I INFgamma, IL-8 L - 8 , MCP - 1 Neutrophils neutrophil g IFN - recruitment and activation recruitment and activation monocyte monocyte T helper 1 polarisation T helper 1 polarisation * CD4+ CTL * CD4+ T helper cells Elimination of rhinovirus Elimination of rhinovirus * NK activity * NK activity * Ig * Immunoglobulins

  19. Acute Rhinosinusitis

  20. B MT MS IT Infections induces changes in sinus mucosa Ventilation and Drainage Inflammation and Remodeling The ostiomeatal complex B Bulla ethmoidalis IT inferior turbinate MT middle turbinate MS maxillary sinus

  21. Microbiology Normal sinuses: Free of growth Acute rhinosinusitis: 2/3 Viral 1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis) Chronic rhinosinusitis: >>Anaerobes: Propionibacterium, Bacteriodes, Peptococcus Aerobes:Staphylococcus, Corynebacterium, Pseudomonas Fungi (» aspergillus fumigatus) Dentogene sinusitis: ?

  22. Guidelines for Acute Rhinosinusitis • Commoncold/ Acute viralrhinosinusitis Occurence in adults: up to 4 times a year URTI: symptoms < 10 days Symptomatictreatmentonly: • Decongestants • Pain relief • Saline drops Can lead to post-viral inflammation of nose and sinuses

  23. Guidelines for Acute Rhinosinusitis • Acute post-viral Rhinosinusitis (ARS) Definition: • ↑symptomsafter 5 daysor • persistent symptomsafter 10 days • lessthan 12 weeks Symptoms: • Nasalobstruction/congestion and/or • Facial pain/pressure • Accompaniedby: • Nasal discharge and/or • Reductionor loss of smell

  24. Guidelines for Acute Rhinosinusitis • Acute post-viral Rhinosinusitis (ARS) Occurence: • onceor more thanonce in defined time period (episodes per year) • complete resolutionbetweensymptoms Appearance: • Mild • Severe • Fever > 38,3°C • Localized pain over the sinuses Streptococcus pneumoniae, Haemophilusinfluenzae and Moraxellacatarrhalis May lead to complications !!

  25. Strength of evidence for treatment of Acute Rhinosinusitis

  26. DBPC trial in 95 patients with acute sinusitis (with history of CRS) All received 2x/d xylometazoline spray (3days) and 2 x 250mg/d cefuroxime (10 days) 47 patients 200µg (two puffs) Fluticasone or 48 patients placebo spray Dolor et al. JAMA Oct 2002

  27. J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.

  28. Nasal GCS and nasal congestion Percent Change in Congestion Symptom Score (Patient-Reported) Days * Percent change in patient-reported congestion symptom score from baseline * * * * * * * * * * * * * *P<0.001 vs placebo. Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64.

  29. Management of Acute Rhinosinusitis

  30. Management of Acute Rhinosinusitisfor ENT-specialist

  31. Acute Rhinosinusitis in de praktijk • 90 %patiënten: 1. bijneusverstopping: volwassene: xylo- of oxymethazoline (max 7 d), pseudo-efedrine(+desloratadine) nasaal corticoid 2x/dag 2. bijpijn: paracetamol: 500 mg 4 à 6 x per dag 3. warme damp en/of neusspoeling met fysiologisch water • <10% patiënten: AMOXICILLINE3 x 1 gr/dag gedurende 7-14 d Indiengeenverbeteringbinnen de 3 dagen: Amoxivervangen door 3X875 Amoxicilline-Clav alternatiefbijallergie: chinolones (ciproxine, avelox, proflox, tavanic, tarivid à 0,5-1g/d)

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