Acute and Chronic Sinusitis - A Practical Guide for Diagnosis and Treatment docx

1 Acute and Chronic Sinusitis A Practical Guide for Diagnosis and Treatment 2 0031003 Presentation Facts • File size: approximately 2013 KB • Number of slides: 81 • Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation • These slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE 3 0031003 Acknowledgments This is a presentation of the American Academy of Family Physicians supported by an educational grant from Aventis Pharmaceuticals The AAFP gratefully acknowledges Harold H. Hedges, III, M.D. and Susan M. Pollart, M.D. for developing the content for the AAFP and Harold H. Hedges, III, M.D. for providing the photo images included in this slide presentation. 4 0031003 Acknowledgments Harold H. Hedges, III, M.D. Private Practice Little Rock Family Practice Clinic Little Rock, Arkansas and Susan P. Pollart, M.D. Associate Professor of Family Medicine University of Virginia Health System Charlottesville, Virginia 5 0031003 Upon Completion of This Presentation You Should be Able To • Be knowledgeable of the causes of and risk factors associated with sinusitis • Differentiate acute from chronic sinusitis • Evaluate patients by history, physical exam, appropriate laboratory and imaging studies, and when indicated screen patients for allergy • Prescribe appropriate medication regimens for acute and chronic sinusitis • Know of the relationships between upper airway (rhinosinusitis) and lower airway disease (asthma) 6 0031003 Rhinosinusitis May be Better Term Because • Allergic or nonallergic rhinitis nearly always precedes sinusitis • Sinusitis without rhinitis is rare • Nasal discharge and congestion are prominent symptoms of sinusitis • Nasal mucosa and sinus mucosa are similar and are contiguous 7 0031003 Scope of Sinusitis • Affects 30-35 million persons/year • 25 million office visits/year • Direct annual cost $2.4 billion and increasing • Added surgical costs: $1 billion • Third most common diagnosis for which antibiotics are prescribed 8 0031003 Normal Sinus • Sinus health depends on: – Mucous secretion of normal viscosity, volume, and composition, – normal mucociliary flow to prevent mucous stasis and subsequent infection; – and open sinus ostia to allow adequate drainage and aeration. • Senior BA, Kennedy DW. Management of sinusitis in the asthmatic patient AAAI J,1996;77:6-19. 9 0031003 Development of Sinuses • Maxillary and ethmoid sinuses present at birth • Frontal sinus developed by age 5 or 6 • Sphenoid sinus last to develop, 8-10 10 0031003 Physiologic Importance of Sinuses • Provide mucus to upper airways – Lubrication – Vehicle for trapping viruses, bacteria, foreign material for removal • Give characteristics to voice • Lessen skull weight • Involved with olfaction [...]... chronic disease • Decrease exacerbations of asthma or other secondary diseases • Do so in a cost-effective way! 0031003 32 Treatment of Acute Sinusitis • Antihistamines recommended if allergy present – Oral or topical • Decongestants – Oral or topical • • • • 0031003 Antibiotic when indicated (bacteria) Nasal irrigation Guaifenesin 20 0-4 00 mg q 4-6 hrs Hydration 33 Decongestants • Topical nasal sprays... Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill • Disease clears with appropriate medical treatment 0031003 30 Physical Findings • Mucopurulent nasal discharge – Highest positive predictive value • Swelling of nasal mucosa • Mild erythema • Facial pain (unusual in children) • Periorbital swelling 0031003 31 Objectives of Treatment of Acute Bacterial Sinusitis • Decrease... (children >90 days) • Some guidelines add treatment failure + a positive imaging study 0031003 16 Recurrent Acute Bacterial Sinusitis • Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic • 3 episodes in 6 months or 4/year 0031003 17 Acute Sinusitis Imposed on Chronic Sinusitis • Patients with chronic, low grade symptoms... middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain • Posterior ethmoids drain into the upper meatus • Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it 0031003 14 Viral Rhinosinusitis • Most upper respiratory infections are viral • Short lived, last less than 10 days • Sinus mucosa as well as nasal mucosa is... clear without antibiotics • Treatment: decongestants, nasal lavage, rest, fluids 0031003 15 Classification of Bacterial Sinusitis • Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days) • Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 3 0-9 0 days) • Chronic sinusitis- symptoms lasting more than 12... Physical trauma • Scuba diving • Foreign body • Cleft palate • Dental disorders • Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis 0031003 29 Acute Bacterial Sinusitis • Usually begins with viral upper respiratory illness • Symptoms initially improve, but then … • Symptoms become persistent or severe • Persistent… 1 0-1 4 days but fewer than... 0031003 26 Causes of Mechanical Obstruction • Deviated nasal septum • Concha bullosa • Foreign body • Nasal polyps • Congenital atresia • Lymphoid hyperplasia • Nasal structural changes found in Downs syndrome 0031003 27 Vasculitides, Autoimmune and Granulomatous Diseases • Churg-Strauss vasculitis • Systemic lupus erythematosis • Sjogren’s syndrome • Sarcoidosis • Wegener granulomatosis 0031003 28 Other... (limit use to 3-7 days) – – – – – Phenylephrine Oxymetazoline Naphthazoline Tetrahydrozoline Zylometazoline • Topical nasal spray (unlimited daily use) – Ipatropium • Oral – Pseudoephedrine 3 0-6 0 mg – Phenylephrine 2-4 times/day 0031003 34 Treatment of Acute, Uncomplicated Sinusitis • Antibiotic may not be indicated – Many are viral – Benefit of antibiotics are only moderate – Weigh factors of cost,... only moderate – Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions 0031003 35 Antibiotics for Acute Bacterial Sinusitis • Amoxicillin 500 mg tid for 1 0-1 4 days – First line choice in most areas – Local differences in antibiotic resistance occur • Where beta-lactanase resistance is an issue – Amoxicillin/clavulanate – Cefuroxime – Cefpodoxime – Cefprozil 0031003 36.. .Sinusitis Infectious or noninfectious inflammation of 1 or more sinuses • 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells – – – – 0031003 Frontal Maxillary Ethmoid Sphenoid 11 Normal Water’s and Towne’ s Views of the Sinuses 0031003 12 Lateral View Showing Normal Sphenoid Sinus 0031003 13 Ostiomeatal Complex • Ostiomeatal complex is that area under . 1 Acute and Chronic Sinusitis A Practical Guide for Diagnosis and Treatment 2 0031003 Presentation Facts • File size: approximately 2013 KB •. presentation of the American Academy of Family Physicians supported by an educational grant from Aventis Pharmaceuticals The AAFP gratefully acknowledges Harold H.