Acute en chronische sinusitis

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Acute en chronische sinusitis

• Dienst neus-, keel- en oorheelkunde, hoofd- en
  halschirurgie, Universitair Ziekenhuis, Gent

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Extrinsic functions

• Lighten the skull
• Protection
• Thermic isolation
• Resonance of the voice
• Sound protection
• Air conditioning
• Olfaction

They are physiologically neutral
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Current definitions

• Sinusitis is acute when episodes of infection
  resolve with medical therapy, leaving no
  significant mucosal damage
• Chronic sinusitis is a persistent disease that
  cannot be alleviated by medical therapy alone

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Definition

• Acute sinusitis
• Symptomatic sinus infection in which symptoms
  persist no longer than 6 to 8 weeks or fewer than
  four episodes per year of acute symptoms of 10
  days duration
• When episodes of infection resolve with medical
  therapy leaving with no significant mucosal damage

Kennedy, 1993
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Definition

• Chronic sinusitis
• In adults 8 weeks of persistent symptoms and
  signs or 4 episodes per year of recurrent acute
  sinusitis, each lasting at least 10 days, in
  association with persistent changes on CT 4 weeks
  after medical therapy without interventing acute
  infection

Kennedy, 1993
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Definition

• Chronic sinusitis
• Cannot be alleviated by medical therapy alone and
  involves radiographic evidence of mucosal
  hyperplasia

Kennedy, 1993
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Epidemiology and costs of sinusitis
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Pathophysiology
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Pathophysiology
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Bacterial infection
Mucosal thickening
Retained secretions Tissue inflammation
CLOSED OSTIUM
Culture medium for bacteria
Mucosal congestion Anatomic obstruction
Cilia and epithelium damages
Secretion stagnation
Secretion thickening pH changes
Mucosal gas metabolism changes
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Microbiology acute sinusitis
PREDOMINANT LESS COMMON Hemophilus
influenzae Klebsiella sp. Streptococcus
pneumoniae a-hemolytic streptococcus Moraxella
catarrhalis ß-hemolytic strepococcus ?-hemoly
tic streptococcus Staphylococcus
aureus Pseudomonas sp. Anaerobes
Fusobacterium Peptostreptococci Ba
cteroides Viruses Rhinovirus Parai
nfluenza Influenza
Van Cauwenberge P et al., 1996
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Reasons for recurrences of acute sinusitis ?

• Anatomical ?
• Immunological deficiencies ?
• Allergy ?

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Why does someone develop chronic sinusitis ?

• We do not know!
• impaired ventilation
• impaired drainage
• subclinical infection

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Species Samples Patients (n79) (n25
) n n No growth 3 4 0 0 Coagulase-neg
ative staphylococci 58 73 21 84 Corynebacterium
sp. 25 32 14 56 Enterobacteriaceae 17 22 8 32
Klebsiella oxytoca 2 2 2 8 Proteus
mirabilis 10 12 4 16 Escherichia
coli 8 10 2 8 Enterobacter sp. 1 1 1 4 Staphy
lococcus aureus 14 18 5 20 Streptococcus
viridans 12 15 3 12 Haemophilus
influenzae 5 6 3 12 Streptococcus
milleri 4 5 1 4 Micrococcus sp. 3 4 1 4 Anaer
obes (propionobact.sp. exclu) 24 30 9 36
Peptococcus/peptostreptococcus sp. 23 29 8 32
Bacteroides melanogenicus 1 1 1 4
Bacteroides ureolyticus 9 11 4 16 Propionibacter
ium sp. 55 70 22 88 P. avidum 11 13 7 28
Van Cauwenberge, 1997
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Chronic sinusitis

• Chronic sinusitis is not a primarily infectious
  process but rather one of an ostial obstruction,
  stasis of mucus and impaired ciliary activity
  resulting in an overgrowth of colonizing bacteria
  

Conservative therapy is often insufficient for
managing chronic sinusitis, making surgical
intervention necessary.
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Histopathology acute sinusitis
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Histopathology chronic sinusitis
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Diagnosis

• Acute sinusitis
• History
• Clinical examination
• Standard X-ray
• Chronic sinusitis / complicated cases
• CT-scan

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Diagnosis
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Treatment of acute sinusitis

• WHY treatment ?
• WHEN treatment ?
• WHICH treatment ?

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Treatment of acute sinusitis

• WHY treatment ?

• Symptoms !
• Complications !
• Acute
• Chronic

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Treatment of acute sinusitis

• Symptoms

• Pain!
• Other nasal and paranasal symptoms

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Acute and chronic sinusitis complications

• Orbital complications
• Abscess
• Phlegmonia
• Blindness
• Cerebral complications
• Meningitis
• Extradural abscess
• Intradural abscess
• Osteomyelitis
• Mucocoeles

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Treatment of acute sinusitis

• WHEN treatment ?

• Symptomatic from the start
• Antibiotics after /- 1 week, BUT always in
  acute ethmoid, frontal and sphenoidal sinusitis
  and in case of complications!

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Treatment of acute sinusitis

• WHICH treatment ?

• Antibiotics
• Symptomatic
• analgesics
• vasoconstrictors (topical/oral)
• steroids

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Conditions for a good antibiotic therapy

• Good spectrum
• Good tissue penetrance and local activity
• Minor side-effects
• Good tolerance
• Creating minimum or non resistency
• Not expensive
• Easy availability

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Treatment first choice

• Amoxicillin ( ? clavulanic acid)
• Second generation cephalosporins (Cefuroxim
  axetyl)
• Macrolides

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Treatment of subacute sinusitis

• 3 weeks to 3 months after the acute onset

• WHY treatment ?
• evolution towards chronicity

• WHICH treatment ?
• Antibiotics (at least 3 weeks)
• Sinus irrigation in case of maxillary sinusitis

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Treatment of recurrent acute sinusitis

• ????
• Treatment of predisposing factors
• Immunomodulators
• Surgery
• NSAID
• Topical steroids

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Treatment of chronic sinusitis
Symptoms longer than 8 weeks

• WHY medical treatment ?
• to avoid surgery
• WHEN medical treatment ?
• always try it
• WHICH medical treatment ?
• antibiotics
• corticosteroids

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BEFORE SURGERY
AFTER SURGERY
Watelet J.B., M.D.