E.B.M. FOR MYTHICAL BEASTS

NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER LAS VEGAS, NV

SINUSITIS &UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

TITLE

DOGMA

INTRO

CLASSIFICATION

GOALS

E.B.M.

DIAGNOSIS

UNICORNS

E.B.M.

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

WARNING

E.B.M.“The conscientious,

explicit and judicious use of current best evidence in

making decisions about the care of the individual

patient.”-David Sackett, MDSackett DL, et al. BMJ 1996; 312(7023):71-2

TITLE

DOGMA

INTRO

CLASSIFICATION

GOALS

E.B.M.

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

E.B.M.

DISEASE

WARNING

TITLE

DOGMA

INTRO

CLASSIFICATION

GOALS

E.B.M.

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

THE PROBLEM

GOALS

WARNING

DOGMA

INTRO

CLASSIFICATION

GOALS

E.B.M.

DIAGNOSIS

UNICORNS

1. Review the dogma

2. Current best evidence

3. Recommendations

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

EVIDENCE

SINUSITISrhinosinusitis

RHINOSINUSITIS

ACUTE

ABRS

AVRS

RECURRENT

INFECT.

ALLERG.

CHRONIC

POLYPS

NO POLYPS

FUNGAL

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

GOALS

E.B.M.

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

SUMMARY

THE DOGMAAVRS

7-10 daysSelf-limited

BilateralNon-purulent

98%-99.5%

ABRS>10 daysNeeds TxUnilateralPurulent

Facial pain0.5%-2%

Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007;45(2):97.

EVIDENCE

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

GOALS

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

RECS

RHINOSINUSITIS

Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72

• Historical featuresFAILSUMMARY

EVIDENCE

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

RHINOSINUSITIS• Historical features

• Physical examFAIL

FAIL

Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

RHINOSINUSITIS

Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician. 2004 Nov 1;70(9):1685-92.

• Historical features• Physical exam• Purulence

FAIL

FAIL

FAIL

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

RHINOSINUSITIS

Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med. 1994;330(1):25

• Historical features• Physical exam• Purulence• Radiology

FAIL

FAIL

FAIL

FAILEPIC

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

DOGMA

CLASSIFICATION

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

UNICORNS

A.B.R.S.

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

DOGMA

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

THE END

A.B.R.S.

OCCULAR/ORBITAL

SEVEREHEADACHE

FACIALSWELLING

ALTEREDMENTATION

Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and

Prevention. Annals of Emergency Medicine. 2001;37(6):703-10

• No cases due to placebo

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

DIAGNOSIS

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

THE PROBLEM

80% Receive antibiotics!!

Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and

Prevention. Annals of Emergency Medicine. 2001;37(6):703-10

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEMWARNING

UNICORNS

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

EVIDENCESystematic Review

Williams JW Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a systematic literature review. In: Douglas R, et al., eds. Acute Respiratory Infections Module of The Cochrane Database of Systematic Reviews. The Cochrane Library.

1997.

ABX47% at 10-

14d81% Cure

No ABX32% at 10-

14d66% Cure

NNT = 7

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

EVIDENCE

Stalman W, van Essen GA, et al. Br J Gen Pract. 1997;47:794-9

Lancet. 1997;349:683-7THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

EVIDENCE

Lancet Infect Dis. 2008;8(9):543

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

WARNING

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

SUMMARYDisease rare

Diagnosis difficult

Mostly harmless

Treatment modest

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

SUMMARY

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

THE PROBLEM

80%

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Int Med. 2001;134(6):495-97

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

TREATMENT

SINCE:• Most ARS is viral• Bacterial/viral cannot be

differentiated• Most ABRS improves without Tx

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

TREATMENT

RECOMMENDED:• Symptomatic Tx and

reassurance• Pain medication• Decongestants

• Abx only for severe symptoms• Cover for s. pneumoniae and h.

influenza

THE END

UNICORNS

RECS

SUMMARY

EVIDENCE

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

THE END

UNICORNS

RECS

SUMMARY

SINUSITIS E.B.M. FOR MYTHICAL

BEASTS

& UNICORNS

THE END

UNICORNS

RECS

QUESTIONS?