acute rhinosinusitis: diagnostic - therapy - complications · orbital cellulitis and abscess...
TRANSCRIPT
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Acute Rhinosinusitis: Diagnostic - Therapy -
Complications
Ariane Baumann
Sommerschule SGORL 24.8.2018
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Table o( Contents
1. Epidemiology 2. Defini9on and Classifica9on of ARS 3. Pathophysiology of ARS 4. Predisposing factors 5. Clinical diagnos9c 6. Treatment of ARS 7. Complica9ons
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Epidemiology Seasonal viral infections of upper airways are very common!• 2-3/year in adults, 6-8 in children
• 90% of infections of upper airway show RS-symptoms• Mostly managed in primary care, primary cause virus
• Only 0,5-2% of viral infections are complicated by bacterial infection (ABRS)
• But acute RS = 5. most common diagnosis for prescription of antibiotics in US
• Complications of RS are rare but serious and potential dangerous clinical events
(SAHP. Antimicrobial treatment guidelines for ABRS. OtolaryngolHead Neck Surg 2004; 130 Fokkens WJ, Lund VJ et al. EPOS 2012 POSITION PAPER on RS and Nasal polyps, Rhinology V 50, Suppl. 23, 2012)
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Rhinitis and sinusitis usually coexist and are concurrent in most patients, thus the correct terminology is
Rhinosinusitis
(EPOS 2012 position paper, Rhinology suppl 23)
Defini9on of Rhinosinusi9s
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Defini9on of Rhinosinusi9s in adults
Inflammation of the nose and paranasal sinuses characterised by two ore more symptoms:
- nasal blockage/obstruction/congestion - nasal discharge - +/- facial pain/pressure - +/- reduction or loss of smell
(EPOS 2012 position paper, Rhinology suppl 23)
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Defini9on of Rhinosinusi9s
and either • endoscopic signs of
- nasal polyps - mucopurulent discharge (primarly middle meatus) - oedema/mucosal obstruction (primarly mid. meatus)
• and/ or CT changes
- mucosal changes within the ostiomeatal complex and/or sinuses
(EPOS 2012 position paper, Rhinology suppl 23)
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Defini9on of RS in children
Inflammation of the nose and paranasal sinuses characterised by two ore more symptoms:
- nasal blockage/obstruction/congestion - nasal discharge - +/- facial pain/pressure - +/- cough
(EPOS 2012 position paper, Rhinology suppl 23)
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and either • endoscopic signs of
- nasal polyps - mucopurulent discharge (primarly middle meatus) - oedema/mucosal obstruction (primarly mid. meatus)
• and/ or CT changes
- mucosal changes within the ostiomeatal complex and/or sinuses
(EPOS 2012 position paper, Rhinology suppl 23)
Defini9on of RS in children
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Defini9on of Rhinosinusi9s
Acute Rhinosinusitis < 12 weeks with complete resolution of symptoms
Chronic Rhinosinusitis
≥ 12 weeks without complete resolution of symptoms
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Comon cold
Sy < 10d
(EPOS 2012 position paper, Rhinology suppl 23)
Classifica9on of acute RS
(EPOS POSITION PAPER on Rhinosinusitis and Nasal polyps, Rhinology 2012)
viral ARS
bacterial ARS
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Pathophysiology
Infectious: Non infectious: viral allergic viral- bacterial toxic bacterial Foreign body fungal (CAVE Immune state) Tumour Systemic diseases
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Virus
• Most common: rhinovirus and coronavirus • Other: influenza- / parainfluenza virus,
adenovirus, respiratory syncytial virus and enterovirus
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Bacteria (ABRS)
• Streptococcus pneumoniae (20- 43%) • Haemophilus influenzae (22- 35%) • Moraxella catarrhalis (child) (10- 20%)
• S. aureus (4-8 %) • Streptococcus ssp, S.pyogenes, anaerobic
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Predisposing factors • Anatomical factors: Ostiomeatal obstruction by
anatomical variations, posttraumatic or inflammatory changes, post surgical scars, tumours or foreign bodies, adenoid (children)
• Dental/ odontogenic infections
• On- going allergic inflammation and cigarette smoke (?) (Cilliary impairment)
• Environmental exposures, seasonal trends
• Role of laryngopharyngeal reflux unclear
• Chronic concomitant diseases
• Poor mental health, anxiety, depression
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Diagnosis
History! - ARS: diagnosis is clinical and relies on presence
and duration of typical symptoms (major and minor symptoms for up to 12 weeks)
- Differential Diagnosis: Allergic rhinitis, orodental disease, barosinusitis, facial pain syndrome, vasculitis, acute invasive fungal RS (immuno-suppressed patients)
- Complications are rare but serious: red flag symptoms!
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Special forms of ARS
Dentogenic sinusitis • Aet: : infections/granuloma of root of the tooth,
fistula after tooth extraction • often anaerobes (foetide odor) • typical one side • diagnosis: consider OPG
Barosinusitis • Aet: : after pressure surges (diving, flights) • typical history • Tx: decongestans local and systemic
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Diagnosis: clinical examina9on
Anterior rhinoscopy and nasal endoscopy, inspection of maxillofacial area, temperature
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Diagnosis: addi9onal tools
• Laboratory: CRP, Lc, Procalcitonin
• Bacteriology: not required (but in research settings, atypical recurrent disease, immunosuppressed patients)
• Imaging: not required in diagnosis of ARS - Plain sinus x-ray: insensitive, of limited usefulness – CT ore cone- beam CT: imaging of choice in
very severe disease, in immunocompromised patients, or suspicion of complication (Benninger MS et al. Otolarngol Head Neck Surg 2002; 127: 7-12)
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Treatment of ARS
• Nasal decongestants ((xylometazoline) • Intranasal corticosteroids (+) EO, Bachert C 2005)
• Analgetics (NSAID, Aspirin or Paracetamol) • Nasal irrigation (isotonic or hypertonic saline water)
• Antihistamines oral or intranasal (-) • Zinc, Vitamin C, Probiotics (?) • Mucolytics (-) • Herbal compounds
• Antibiotics ??
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An9bio9cs: yes or no?
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(EPOS- Guidelines 2012, Rhinology, Suppl 23, 2012) (EPOS POSITION PAPER on Rhinosinusitis and Nasal polyps, Rhinology 2012)
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(EPOS- Guidelines 2012, Rhinology, Suppl 23, 2012) (EPOS POSITION PAPER on Rhinosinusitis and Nasal polyps, Rhinology 2012)
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When is it gePng «dangerous» ?
• High untreatable persistent fever • Periorbital oedema/erythema • Displaced globe/ protruding eyeball • Reduced vision acuity, double vision • Severe unilateral or bilateral frontal headache,
frontal swelling • Signs of meningitis or neurologic signs
Suspicion of bacterial complication
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• Orbital: preseptal cellulitis subperiosteal abscess orbital cellulitis and abscess (cavernous sinus thrombosis)
• Intracranial: epidural or subdural abscess brain abscess, meningitis, encephalitis
• Osseous: osteomyelitis from facial skeleton
Complica9ons of RS
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(Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int Ophthalmol Clin 1996; 36. Netter FH, Atlas of Human Anatomy 1997)
Orbital complica9ons
Spread in children from ethmoid sinus
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Stadien nach Chander (1970)
Stadien nach Moloney (1987)
Preseptal celluli9s I I
Orbital celluli9s II III Subperiosteal abscess III II Orbital abscess IV IV
(Cavernous sinus thrombosis) V V
(Chander JR et al. The pathogenesis of orbital complications. Laryngoscope 1970; 80. Moloney JR et al. Preseptal cellulitis, subperiostal abszess due to sinusitis; J Laryngol Otol Suppl 1987;12)
Orbital complica9ons
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• Direct or venous spread of infection in
preseptal area, anterior to orbital septum
• Often as complication of URTI, dacryocystitis or skin infection
• Sy: orbital pain (not always!), eyelid oedema, erythema, (sometimes) fever
• No proptosis, no chemosis, no limit in eye movement
• Clinical diagnosis, CT not always needed
• Tx: oral antibiotics, if not aggressively treated, spread beyond orbital septum
(Bailey JB. Head Neck Surgery, 2001; Pediatric Rhinosinusitis, 956-960)
Preseptal Celluli-s
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• Infection spread over „osseous barrier“, abscess between periorbit & orbit outside ocular muscles, extraconal
• Oedema, erythema, chemosis, proptosis of eyelid, limited ocular motility
• Diagnostic: CT scan with contrast and control of visual acuity and pressure!
• Tx: in small children with abscess volume <1ml / normal visual: 24-48h antibiotics i.v. Otherwise: surgical drainage
(Caversaccio M, Heimgartner S, Aebi C. Laryngo-Rhino-Otol 2005; 84: 817)
Subperiosteal abscess
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• Infection involve the orbit intraconal
• Proptosis, chemosis, limitation of ocular motion or ophthalmoplegia, visual acuity diminishes
• Dg: CT scan with contrast, if intracranial complication is suspected MRI
• Tx: AB i.v. and surgery
• CAVE: Sepsis, spread intracranial
Orbital celluli-s or orbital abscess
(Bailey JB. Head Neck Surgery, 2001)
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• Further spread to cavernous sinus thrombophlebitis causing sepsis and multiple cranial nerve involvement, often bilateral spread
• Oedema, proptosis, chemosis, papilla oedema, complete ophthalmoplegia, spiking fever, meningitis signs
• Dg: MRI and/or CT scan with contrast
• Mortality rate of 30% (adults)!
• Tx: high doses antibiotics iv, anticoagulants (?), surgical drainage of corresponding sinus
Cavernous sinus thrombosis
(Bailey JB. Head Neck Surgery, 2001)
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§ Mostly spread from frontoethmoidal or sphenoidal infections
§ Meningitis, subdural- or epidural abscess, brain abscess, cavernous sinus thrombosis
§ Pathogens pass through diploic veins or per continuitatem by eroding sinus bone or haematologically (sinus cav)
§ Symptoms can be non- specific!
• Severe frontal/ retro orbital headache
• High fever • Increased intracranial pressure, meningeal irritation, focal neurological deficits (III, VI or VII cranial nerve palsy)
• Behavioural changes, altered consciousness
Endocranial complica-ons
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Diagnostic: CT with contrast and/ or MRI
Therapy: management always multidisciplinary
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• Most common: osteomyelitis of frontal bone (spongiosa!) & maxillary (dental?) bone, sphenoidal bone: rare (N III,IV,V,VI palsy)
• Frontal sinus osteitis/osteomyelitis → vascular necrosis → frontal subperiostal abscess („Pott‘s Puffy tumour“) or frontocutanous fistula
• Posterior wall → via valveless diploic veins → cranial complications°
• Dg: CT with KM +/- MRI
Bone complica-ons
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§ In acute uncomplicated RS with mild symptoms: “watch and wait”
§ In acute RS with severe or prolonged symptoms: • topical corticosteroids and consider antibiotics
recheck diagnosis/ differential diagnosis • in immune compromised patients think of
complications
§ Suspicion of complication: always CT scan with contrast of paranasal sinus & head +/- MRI
Summary