Sinusitis & Its Treatment

Presented by: Sim Sui Theng Hospital Miri

Introduction Pathophysiology Microbial Etiology Clinical Manifestations Treatment Summary References 

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Sinusitis – An inflammation process involving the mucous membranes of the paranasal sinuses and/or underlying bone  Normally involved the nasal mucosa  rhinosinusitis  Can be classified based upon duration of symptoms: 

• Acute – sudden onset and lasts up to 4 weeks • Subacute – lasts between 4 – 12 weeks • Chronic – lasts at least 12 consecutive weeks

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Fig Fig2: 1:Diagram Schematic of the drawing lateral showing nasal wall location and turbinates of the frontal, in relation ethmoid, to the frontal and maxillary and sphenoid sinuses sinuses and Eustachian tube orifice 4

Allergy, viral infections or air pollutants induce local inflammation in sinonasal mucosa Approximation of mucosal surfaces in the narrow channels of OMC* Swelling leads to impairment of mucociliary clearance & obstruction of the sinus ostia

*OMC- Osteomeatal complex

Sinus secretions pool & thicken, providing excellent culture medium for m/o

Sinusiti s

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Acute Sinusitis

Chronic Sinusitis

-Well defined - Virus (most common), Bacteria (2%) - Examples of viruses: Rhinovirus, parainfluenza, influenza virus, RSV, adenovirus - Bacterial: • Community-acquired:  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella catarrhalis  Staphyloccus aureus  Anaerobic bacteria • Nosocomial:  Staphylococcus aureus  Streptococcal species  Pseudomonas species  Escherichia coli  Klebsiella species  Other Gram negative bacteria

-Not well defined - Normally involve polymicrobial infections - Anaerobes

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 Nasal congestion  Purulent nasal discharge  Maxillary tooth discomfort  Facial pain/pressure (worse

bending forward)  Headache  Fever (Non-acute)  Fatigue  Cough  Ear pain/ear fullness

when

Rhinosinusitis

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(1)

Acute sinusitis

 -

Viral rhinosinusitis Goal: Suppressing the full development of symptoms, especially the nasal fluid production that leads to nose blowing At the 1st sign of cold…

1st generation antihistamine (Eg. Chlorpheniramine) + NSAID (Eg. Ibuprofen) Administer q12H until cold symptoms clear

May add an oral decongestant (pseudoephedrine) and/or cough suppressant (dextromethorphan) as needed No improvement after 7-10 days? Antimicrobials may be required to treat secondary bacterial sinusitis

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

Community-acquired bacterial sinusitis Recommended antibiotics

Centers for Disease Control and Sinus and Allergy Health Partnership Prevention (CDC) Amoxycillin (1.5 to 3.5g/day)

Mild disease (No antibiotics in the last 4-6 weeks) -Amoxycillin-clavulanate (625mg bd) -Amoxycillin (1.5-3.5g/day) -Cefuroxime axetil (500mg bd) -Levofloxacin (500mg od) -Moxifloxacin (400mg od)

Doxycycline (100mg bd)

Mild disease (antibiotics in the last 4-6 weeks) OR Moderate disease (no antibiotics in this time frame): -Amoxycillin (3-3.5g/day) -Same as above (amoxycillin-clavulanate, cefuroxime, levofloxacin, moxifloxacin)

Trimethoprim-Sulfamethoxazole Moderate disease (antibiotics in the last 4-6 (1 tablet bd) weeks): -Amoxycillin-clavulanate, levofloxacin,

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 -

 -

-

Nosocomial bacterial sinusitis Antimicrobial coverage should be directed at S. aureus and the Gram –ve bacteria based upon the sinus aspirate C&S test Fungal sinusitis Mainly involve the immunocompromised patients Surgical intervention – diagnostic biopsy and for debridement of the infection Empirical antifungal therapy: IV Amphotericin B 1mg/kg/day, duration depends on underlying host’s immune status extent of surgical debridement & response to therapy Chronic suppressive therapy following amphotericin B: oral itraconazole or voriconazole 10

(2) 



 



Chronic sinusitis Antimicrobials: Amoxycillin-clavulanate (625mg bd) OR cefuroxime (500mg bd) for 21 days OR clarithromycin 500mg bd Decongestants: pseudoephedrine (short-term use); do not use topical nasal decongestant spray for chronic cases  rebound rhinitis after 72H use Nasal irrigation: irrigate twice a day with warm saline solution using a bulb syringe Nasal steroids: 2 puffs of nasal spray/day (decrease mucosal inflammation and swelling, esp allergy) Adjunctive agents: Mucolytic agents (Eg. Guaifenesin); Antihistamines 11



Antihistamines

• MOA: Competes with histamines for H1-receptor sites on • • • •

effector cells in the gastrointestinal tract, blood vessels, and respiratory tract Side effects: drowsiness & sedative, dry mouth, constipation, urinary retention, nausea & vomiting and epigastric pain Newer antihistamines: less sedative Some patients may respond better with older antihistamines Counseling point:

 Drowsiness, blurred vision, lightheadedness – avoid driving, handling machinery Consipation – take more liquids, regular exercise, fibercontaining diet Dry mouth – frequent mouth care Avoid alcohol, other antihistamines or mood stabilizers

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Table 1: Relative Adverse Effect Profile of Antihistamines Medication

Relative Sedative Effect

Relative Anticholinergic Effect

Low Low Low

Moderate Moderate Moderate

High Moderate High

High High High

Low Moderate

Low to none Low to none

High

High

Low to moderate Low to none Low to none

Low to none Low to none Low to none

Alkylamine Class Brompheniramine maleate Chlorpheniramine maleate Dexchlorpheniramine maleate Ethanolamine Class Carbinoxamine maleate Clemastine fumarate Diphenhydramine HCl Ethylenediamine Class Pyrilamine maleate Tripelennamine HCl Phenothiazine Class Promethazine HCl “Non-sedating” Peripherally Selective Class Cetirizine Fexofenadine Loratadine

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

Decongestant

• MOA: Sympathomimetic agent which acts on

adrenergic receptors & produces vasoconstriction. It shrinks swollen mucosa & improve ventilation. • Topical decongestant: drops/spray • Problem: prolonged use can cause rebound vasodilation (rhinitis medicamentosa) ~ if use more than 3-5 days • Side effects: burning, stinging, sneezing & dryness of nasal mucosa • Counseling point: To use as small dose as infrequently as possible & only when absolutely necessary (Eg during bedtime to aid falling asleep); duration: limited to 3-5 days 14

Table 2: Duration of Action of Topical Decongestants Medication Duration (hr) Short Acting Phenylephrine HCl

Up to 4

Intermediate Acting Naphazoline HCl Tetrahydrozoline HCl

4–6

Long Acting Oxymetazoline HCl Xylometazoline HCl

Up to 12

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Table 3: Oral Dosages of Commonly Prescribed Antihistamines and Decongestan Dosage and Interval Medication

Adults

Children

Antihistamines Chlorpheniramine maleate, plain

4mg q6H

6-12 yr: 2mg q6H 2-6 yr: 1mg q6H

Chlorpheniramine maleate, sustained release

8 – 12mg daily at bedtime or 8 – 12mg q8H

6-12 yr: 8mg at bedtime <6 yr: Not recommended

Diphenhydramine HCl

25 – 50mg q8H

5mg/kg/day q8H (up to 25mg per dose)

Clemastine fumarate

1.34mg bd to 2.68mg tds

Not recommended

Loratadine

10mg od

10mg od

Fexofenadine

60mg bd

6-11 yr: 30mg bd

Cetirizine

5 – 10mg od

>6 yr: 5mg od

60mg q4-6H 120mg q12H for SR tablet

6-12 yr: 30mg q4-6H 2-5 yr: 15mg q4-6H

25 – 50mg q4H

2-3 mg/kg/day divided q4H (up 16 to 25mg q4H)

Decongestants Pseudoephedrine Ephedrine sulfate

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Nasal Steroid

• MOA: Reduce inflammatory by blocking mediator release,

suppress neutrophil chemotaxis, reduce intracellular edema & cause mild vasoconstriction • Eg: Budesonide nasal spray, beclomethasone dipropionate • Side effects: sneezing, stinging, headache, epistaxis • Should NOT be used in pts with nasal septum ulcers or recent nasal surgery or trauma • Counseling point:  Blocked nose should be cleared with decongestant before administration to ensure adequate penetration Avoid sneezing/blowing their nose at least 10 mins after administration

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Table 4: Dosage of Nasal Steroids Medication

Dosage and Interval

Beclomethasone dipropionate  >12 yr: 1 inhalation (42µg) per nostril 2-4X/day (max: 336µg/day)  6-12 yr: 1 inhalation per nostril 3X/day Beclomethasone dipropionate, monohydrate

 >12 yr: 1-2 inhalations once daily  6-12 yr: 1 inhalation per nostril bd

Budesonide

 >6 yr: 2 sprays (64µg) per nostril a.m. & p.m., or 4 sprays per nostril a.m. (max: 256µg)

Fluticasone

Adults: 2 sprays (100µg) per nostril once daily; after a few days decrease to 1 spray per nostril Children >4 yr and adolescents: 1 spray per nostril od (max: 200µg/day)

Mometasone furoate

 >12 yr: 2 sprays (100µg) per nostril od

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Metson, R & Sindwani, R., 2007. Chronic sinusitis. UpToDate (15.2) Snow, V,et al. Ann Intern Med 2001; 134:495. Position paper endorsed by the American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2000; 123:S1 Gwaltney, JM, 2007. Acute sinusitis and rhinosinusitis in adults. UpToDate (15.1) Katzung, BG: Basic & Clinical Pharmacology Lexi-Comp-Drug Information Handbook International, 14th Edition

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