国外鼻窦炎精彩.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Acute and Chronic Rhinosinusitis,Pathophysiology,diagnosis,and management.,AAAAI Rhinosinusitis Committee,Updated 2006,Rhinosinusitis,Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses,Sinus and Allergy Health Partnership,Meltzer et al.JACI 2004;114:155,Rhinosinusitis,More accurate term than“sinusitis”since almost always preceded by or concomitant symptoms of rhinitis,Acute Up to 4 weeks,Subacute 4 to 12 weeks,Chronic,12 weeks,Acute Rhinosinusitis,Question,Is acute rhinosinusitis usually viral or bacterial?,Acute Rhinosinusitis,1 billion viral URIs each year,0.5%-2%lead to secondary bacterial infection of the sinuses.,1,2,Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days,1,Gwaltney Clin Infect Dis 1996;23:1209,2,Berg et al.Rhinology 1986;24:223-5,Obstruction of the Sinus Ostium Produces Acute Rhinosinusitis,Kern EB JACI 1984:73:25,Retained Thick Secretions,Stagnation,Transudation,Viscid Fluid,Ciliary,Dysfunction,Vasodilation,Mucous Gland,Dysfunction,O,2,Coronal View in Relation to Facial Structure,Koepke,J.W.,Dolen,W.K.,Spofford,B.,&Selner,J.C.(1998).,Rhinolaryngoscopy,(2,nd,ed.).Allergy Respiratory Institute of Colorado.,Anatomic Drainage Pathways in the Sinuses,Sinus Area,Frontal,Anterior ethmoid/,Maxillary,Posterior ethmoid/,sphenoid,Drainage pathway,Nasofrontal duct,Ostiomeatal unit,Sphenoidethmoidal,recess,Other Clinical Signs of Acute Rhinosinusitis,Tenderness overlying the sinuses,Nasal erythema,Purulent nasal secretions,Increased posterior pharyngeal secretions,Fetid breath,Periorbital edema,Ear examination may reveal eustachian tube dysfunction,Diagnosis of Acute Bacterial Rhinosinusitis,Acute clinical pattern,Symptoms 10 days and 28 days,Objective confirmation either/or,Nasal exam documenting purulent d/c beyond the nasal vestibule,Rhinoscopy,Endoscopy,Posterior pharyngeal drainage,CT scan Not recommended for routine management,May be helpful in complex cases,Meltzer et al.JACI 2004;114:155,Radiographic Evidence of Rhinosinusitis,Air fluid level,Sinus opacification,Mucus membrane thickening of 4 to 6 mm or more,Advantages of CT Scan in Rhinosinusitis Diagnosis,More sensitive and specific than plain sinus radiographs,Allows assessment of ostiomeatal unit patency(OMU),Useful in intubated patients,Axial cuts provide additional anatomic information,Useful in complicated cases with CNS,bony,or orbital extension,Protocol for Limited Sinus CT Scan,Patient prone in Waters position(bring table up,until it stops automatically so you can get the full 25,o,tilt),Positioning:,Scout View:,Lateral skull,Place lines(to get correct angle,place cursor at,front of sinuses and maxilla.If this angle is 25,o,or less,place lines as follows:,Slice#1:Place line in middle of frontal sinuses.,Slice#2:Place line where Coronal suture intersects at,top of orbit.,Slice#3:Place line halfway between slice#1 and#2,(Note:To see OMU eventually you may need,to take several slices in this area.),Slice#4:Place line mid-sphenoid.,Scout X-ray,Landmarks for performing a limited sinus CT scan in the coronal plane,Uncinate Process,Ethmoid Sinus,Middle Turbinate,Infundibulum,Inferior Turbinate,Nasal Septum,Maxillary sinus,Nasal Septum,Normal Sinus CT Scan through the OMU,Maxillary sinus,Eyeball,Ethmoid sinus,Nasal cavity,Blow-up View of the Ostiomeatal Unit Area,Maxillary sinus,Middle turbinate,Uncinate process,Maxillary infundibulum,Ethmoid sinus,Obstruction of the OMU with Associated Acute Sinusitis,Sinusitis in the,ethmoid sinus,.,Sinusitis in the,maxillary sinus,.,Local Factors Predisposing to Rhinosinusitis,Allergic rhinitis,URI,Anatomic abnormalitiy:,Deviated septum,Concha bullosa,Enlarged adenoids,Haller cells,Nasal polyps,Tumor,Foreign body,Trauma,Barotrauma,Diving,swimming,Smoke,Topical decongestant abuse,Nasal intubation,Systemic Factors Predisposing to Rhinosinusitis,Immune deficiency,IgA deficiency,Panhypogammaglobulinemia,IgG subclass deficiency,HIV,Cystic fibrosis,Ciliary disorder,Wegeners granulomatosis,Gastroesophageal reflux,Ominous Signs in Rhinosinusitis,Facial swelling/erythema over an involved sinus,Visual changes,Abnormal extraocular movements,Proptosis,Periorbital inflammation/edema,Intracranial or CNS involvement,Antibiotics for Acute Sinusitis,Cochrane Database Review(2004)Peds,Available evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term.,Cochrance Database Review(2004)Adults,Current evidence is limited but supports the use of antibiotics for 7 to 14 days,Weigh the moderate benefits of abx treatment against the potential for adverse effects,Antibiotics for Acute Maxillary Sinusitis in Adults,Searched from MEDLINE and EMABASE,contacts with pharmaceutical companies,and bibliographies of included studies,Results,49 trials(n=13,660),20 were double blind,Compared to controls,abx improved clinical cures,Radiographic outcomes improved with abx,Comparison between classes of abx showed no significant differences,The Cochrane Database of Systematic Reviews 2004;1:1-69,Acute Bacterial Rhinosinusitis:Which antibiotic to use?,No randomized,placebo-controlled trials of antibiotic treatment for ABRS using pre-and post-treatment sinus aspirate culture,Antibiotics,20 to 30%of,S.pneumoniae,are penicillin resistant,30 to 40%of,H.influenzae,and 75 to 95%of,M.catarrhalis,are beta-lactamase positive,When choosing abx consider,Recent abx use(within 6 weeks),Severity of disease,Antibiotics for Acute Rhinosinusitis,FDA approved antibiotics for acute bacterial rhinosinusitis,Amoxicillin,amoxicillin-clavulonate,clarithromycin,cefprozil,cefuroxime axetil,loracarbef,levofloxacin,gatifloxacin,azithromycin,trimethoprim sulfamethoxazole,moxifloxacin,telithromycin,Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg 2004:130:1,Comparison of First-Line vs Second-Line Abx,Objective:compared effectiveness and cost for treatment in uncomplicated ABRS,Retrospective cohort study(n=29,102),Outcome:presence or absence of additional claim for an abx,cost,complications of sinusitis,Piccirillo et al.JAMA 2001;286:1849,List of Antibiotics,1,st,Line,Amoxicillin,TMP-SMX,Erythromycin,2,nd,Line,Clarithromycin,Azithromycin,Augmentin,Cephalosporins,Levofloxaxin,Clindamycin,metronidazole,Results,1,st,Line,Success:90.1%,1 case of periorbital cellulitis,Cost:$68.98,2,nd,Line,Success:90.8%,1 case of periorbital cellulitis,Cost:$135.17 p 12 weeks,Two main subtypes:,CRS without nasal polyps,CRS with nasal polyps,Strongly associated with asthma and aspirin tolerance,Meltzer et al.JACI 2004;114:155,Mechanisms of CRS,Chronic Rhinosinusitis:Risk Factors for Extensive Disease,80 patients with CRS,Factors,Eosinophil 200/uL(OR=19.2,95%CI=5.4-72.7,Asthma(OR=6.8,95%CI=2.2-22),Atopy(OR=4.3,95%CI=1.5-12.8),Age50(OR=6.5,95%CI=2.0-22.2),Hoover GE et al.JACI 1997;100:185-91,Prevalence of Allergy in CRS,Chart review of 113 sinus surgery patients,48 patients included in the study,Allergy testing by RAST or skin testing,57.4%had a positive allergy test,Guman et al.Otolaryngol Head Neck Surg 2004;130:545,Correlation of Allergy and Rhinosinusitis,Retrospective review of 200 patients with FESS,84%with allergies,Predominance of perennial(esp DM),Emanuel et al.Oto H 123:687-91,Allergic Inflammation and Rhinosinusitis,Purpose:ongoing AR enhances infection and inflammation by,S.pneum,in acute sinusitis,BALB/c mice sensitized to ovalbumin by IP injection,Nasal administration of OVA soln,Infection with,S.pneumoniae,Blair et al.JACI 2001;108:424-9,Allergic Inflammation and Rhinosinusitis,Results:,Allergic mice had more bacteria recovered,more inflammation(PMN,eos,monos),Allergic Inflammation and Rhinosinusitis,Blair et al.JACI 2001;108:124.,Correlation of Allergy and Rhinosinusitis,42 patients with CRS underwent RAST and CT scans,Allergic patients had higher CT scores(mean=12),Nonallergic patients had lower CT scores(mean=6)p=0.03,Type of Allergy Among Sinus Surgery Patients,None,Perennial and seasonal,Perennial,Seasonal,Emmanuel et al.Otolaryngol H 13:345,Allergy Immunotherapy for CRS,Study:114 patients with perennial allergic rhinitis and sinusitis,surveyed using the Sinusitis Outcomes Questionnaire.,99%of patients surveyed believed immunotherapy was helpful,72%decrease in days lost from work or school,25%reduction in the use of medications,51%reduction in the overall symptom score,Nathan et al,Ann Allergy Asthma Immunol 2004,Allergic Fungal Rhinosinusitis,Appears to be a subset of CRsNP,Defined by 5 criteria:,allergy to cultured fungi,gross production of eosinophilic mucin that contains noninvasive fungal hyphae,nasal polyposis,characteristic radiographic changes,immunocompetence,Meltzer et al,JACI 2004,114(suppl):155-212.,Role of Infectious Agents in CRS,Fungi,Eosinophilic fungal rhinosinusitis has been proposed,but is controversial.,Bacteria,Superinfection is more common role,rather than primary cause of inflammation and obstruction.,Superantigen from,Staph aureus,has been demonstrated to have a role in nasal polyps.,Biofilm is an attractive but unproven concept.,Osteitis is another unproven concept.,Meltzer et al.JACI 2004;114:155,Fungi and Chronic Rhinosinusitis,Allergic fungal rhinosinusitis,A well-characterized condition involving allergy to fungi and other characteristic features.,Infectious fungal rhinosinusitis,Direct infection of the sinuses(non-invasive vs.invasive).,Eosinophilic fungal rhinosinusitis,A(proposed)non-IgE-mediated inflammatory condition characterized by fungal colonization,local chemotaxis of eosinophils,and inflammation.,Bacterial Superantigen,Local production of IgE specific to staphyloccal enterotoxins,which act as superantigens,in CRSwP,Staph aureus,enterotoxins induce increased severity of eosinophilic inflammation,Increased colonization of,Staph aureus,in swabs of the middle meatus from patients with CRSwP relative to normal controls and patients with CRSsP,Smart,BA,Pediatric Asthma,Allergy and Immunology,2005;18,:,88-98,Diagnosis of CRS,Physical examination,Endoscopy or anterior rhinoscopy,Purulent drainage,Edema or erythema of the middle meatus or ethmoid bulla,polyps,Sinus CT scan,Mucosal thickening,Air-fluid level,Meltzer et al.JACI 2004;114:155,Medical Management of Chronic Rhinosinusitis,Antibiotics,Corticosteroids,Decongestants,Muco-evacuants,Antihistamines,Non-pharmacologic treatment,Microbiology of Chronic Rhinosinusitis,Not well defined because of differences in culturing techniques,prior use of abx,S.pneumoniae,H.influenzae,M.catarrhalis,S.Aureus,coagulase negative,staph,anaerobes,Fungi,Meltzer et al.JACI 2004;114:155,Chronic Rhinosinusitis:Which Antibiotic to Use?,-No antibiotic is approved by FDA for CRS,-We use similar abx as ABRS,Antibiotics for Chronic Rhinosinusitis,Appropriate duration is not well defined,AAAAI and ACAAI Joint Task Force,treat for 3,4 or 6 weeks,continue abx for at least 1 week after the patient is symptom free,Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery,treat 4 to 6 weeks,Corticosteroids,Few controlled studies with nasal steroids,Beneficial when added to abx,Longer infection free interval in CRS,systemic steroids have not been well studied,Adjunctive Therapy,Decongestants,Used as adjuvant treatment,no controlled studies,Mucolytic treatment,1 double blinded study,2400 mg of guaifenesin or placebo in HIV,+,with chronic sinusitis,improvement in congestion and thick secretions,Wawrose et al.Laryngoscope 1992;102:1225,Adjunctive Therapy,Antihistamines,play a role in allergic rhinitis patients with sinusitis,Saline irrigation,may help mucociliary clearance,mild vasoconstrictor of nasal blood flow,Intravenous immune globulin,indicated in patients with impaired humoral immunity,Adjunctive Therapy,Leukotriene antagonists,Useful in patients with CRS with nasal polyps,Nasal Irrigation,211 with sinonasal disease,Irrigated with 250 mL HS using a Water Pik BID for 3 to 6 weeks,Rated nasal symptoms and QOL,Tamooka et al.Laryngoscope 2000:1189-93,Nasal Irrigation,Results,23/30 symptoms improved,QOL improved,92%compliance,83/109(76%)improved,26(24%)reported adverse effects or no benefit,Nasal Irrigation,Improves mucociliary function,Decreases mucosal edema,Decreasing inflammatory mediators,Clearing mucus,Outcomes of Medical Management of CRS,200 pediatric and adult patients,treated with 4 weeks of oral abx,nasal corticosteroids,lavage and topical decongestants,patients followed 1 to 27 months(mean 6 months),all improved,6%required surgery,McNally PA,et al.Allergy and Asthma Proc1997;18:169,Outcomes of Medical Management,Retrospective series of 40 patients,treated with abx for 4 to 6 weeks and 10 days of prednisone,most patients also used nasal steroid spray and saline irrigation,36 had improvement in both symptom and CT scores,Subramanian H,Hamilos DL.Am J Rhinol 2002;16:303,Surgery for Rhinosinusitis,FESS,enlarge sinus ostia,correct anatomic deformities(septal deviation,concha bullosa),create a common cavity for nasal drainage,ventilate sinuses,85%improvement in selected series,Summary,Acute rhinosinusitis is usually related to infection,Antibiotic management is first line,Chronic rhinosinusitis is usually related to inflammation,Further characterization of the condition is important(nasal polyps),Exploration of underlying allergy is important,Management is challenging,