09 - PA 614 2023 Sinus Disease Rathi.pdf

“Sinus Problems” PA EENT Module 9/1/21 Zachary M. Soler, MD, MSc Associate Professor Division of Rhinology and Sinus Surgery Medical University of South Carolina Referrals from PCPs Referrals from ENTs PCP Visits • • • • Early Vague Wide differential Variable pt impact • • • • Late Clear prob...

“Sinus Problems” PA EENT Module 9/1/21 Zachary M. Soler, MD, MSc Associate Professor Division of Rhinology and Sinus Surgery Medical University of South Carolina Referrals from PCPs Referrals from ENTs PCP Visits • • • • Early Vague Wide differential Variable pt impact • • • • Late Clear problem Obvious dx High impact Outline • Anatomy/physiology of the sinuses • Acute sinusitis – – – – Diagnosis Treatment Complications When to refer • Chronic sinusitis – Diagnosis – Medical management – When to refer • Otolaryngology evaluation • Sinus surgery Anatomy Frontal sinus Septum Inferior turbinate Anatomy Osteomeatal complex (OMC) Maxillary sinus Middle turbinate Anatomy Optic nerve Carotid A Sphenoid sinus Physiology – 600-1800ml mucus produced daily – Propelled by mucociliary movement – Movement coordinated toward natural ostium *Kennedy, Hwang: Rhinology: Diseases of the Nose, Sinuses, and Skull Base 2012 Serrano C. Archivos de Bronconeumolgia 2005 Acute Sinusitis Acute Sinusitis Pediatric AAP 2013 Adult AAOHNS 2015 Pediatric and Adult Sinusitis Guidelines are VERY Similar Viral URI • 201 healthy children—community setting • 6 months-3 years old • Followed for 1 year *12% with ≥10 infections/yr Viral URI • • • • • • • • Nasal congestion Nasal drainage—thin/clear thick/discolored Cough—day and night (often worse at night) Variable fever (often in first 48 hours) Fussy Poor sleep Not easy for parents to simply “observe” Education of parents/patients critical Viral URI—Education • Expected # – Kids: 5-6/yr…but could be more—daycare – Adults: 1-2/yr • Typical symptoms and course • Concept of “viral sinusitis” vs bacterial infection Acute Bacterial Sinusitis • Multidisciplinary guideline • Pediatricians, Family Practice, Otolaryngology • 2013—needs updating… Diagnosis of ABS • 1. Persistent Illness (viral URI – – – – ABS) 10 days of symptoms w/o improvement Nasal congestion/drainage or daytime cough Must differentiate between recurrent viral URIs 6-7% of URI • 2. Worsening Course (viral URI ABS) – New or worsening symptoms after initial improvement – Usually after 5-6 days Diagnosis of ABS • 3. Severe Onset (ABS w/o viral URI) – Fever >102.2 – Purulent drainage – Symptoms for 3 consecutive days Diagnosis of ABS • Does NOT include physical exam findings – Edema/purulence seen in viral URI – Anterior rhinoscopy limited • Does NOT include imaging – Plain X-rays—NOT indicated – CT scan of sinuses—NOT indicated • Not specific—viral URI has CT findings in 55-80% • Normal CT does rule out ABS (rare indication) Personal Thoughts • Take a Directed History---patients rarely able to spontaneously give good history • Tease apart current episode from baseline symptoms • Focus on Current Episode first • Exact time course of illness • Specific symptoms (congestion, discolored drainage, pressure/pain, smell loss, etc) • What is most likely explanation? Viral URI, ABS, allergy flare • What is their Baseline like— “How is your nose/sinuses on a typical day when you are not sick”? • Normal, baseline rhinitis (allergic vs nonallergic), baseline congestion only, baseline chronic sinusitis, etc Acute Bacterial Sinusitis Treatment Antibiotic Overuse • 65% of URI receive an antibiotic (inappropriately?) • “Wrong” antibiotic often chosen • Eventually will be tied to reimbursement? ABS Treatment • Oral antibiotics – Offered to all children with diagnosed ABS (Level B) – Exception: Can consider 3 days of observation with repeat evaluation in those with “persistent illness” – Based on 3 high quality RCTs (2 show benefit) – Increases resolution at 10-14 days—NNT 3-5 Which Antibiotic? • “Clinicians should prescribe amoxicillin with or without clavulanate as first-line treatment when a decision has been made to initiate antibiotic treatment of acute bacterial sinusitis” (Level B Recommendation). • Azithromycin NOT recommended • Bactrim NOT recommended Why not just Amoxicillin? • Microbiology of ABS documented in 1980s – Streph pneumo (30%) > H. flu (30%) > Moraxella (20%) > Sterile (20%) • Amoxicillin vs Augmentin in 1980s • Microbiome has changed over time – Haemophilus influenzae type b (Hib) – Pneumococcal conjugate (PCV13) – Antibiotic Pressure Antibiotic Resistance Bacteria % PCN resistant Absolute % Strep pneumo 30 15-50 4.5-15 H. Flu 20 25-50 5-10 Moraxella 20 90-100 18-20 Total Relative % 27.5-45% *Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in children (strong, moderate). IDSA Clinical Practice Guideline 2012 Penicillin Allergic • Non-type 1 hypersensitivity – Cefdinir, Cefuroxime, Cefpodoxime, Ceftriaxone – Risk of anaphylaxis extremely low • Type 1 hypersensitivity – Cefdinir, Cefuroxime, Cefpodoxime – Consider referral for skin testing first (timeliness?) – Clindamycin/linezolid plus Cefixime (<2yr and serious infection) – Levofloxacin—special circumstances • Bactrim and Azithromycin NOT indicated Antibiotic Length • • • • No consensus 10 days minimum Most commonly 10-14 days 7 days after resolution of symptoms Adjunct Measures • Decongestants • Antihistamines • Saline Irrigation -No studies met Cochrane inclusion criteria -All RCTs with methodological flaws -AAP CPG gives “No Recommendation”(inadequate data) -EPOS 12 No good evidence” (Evidence A-) Topical Steroid Spray -AAP CPG gives “No Recommendation”(inadequate data) -EPOS 12 “Reasonable evidence to support” (Evidence A). Possible Courses Back to Baseline (normal) ABS Treatment Back to Baseline then Recurrence (recurrent acute sinusitis?) Fails to Resolve (subacute sinusitis or chronic sinusitis?) Possible Courses Back to Baseline (normal) ABS Treatment Back to Baseline then Recurrence (recurrent acute sinusitis?) Fails to Resolve (subacute sinusitis or chronic sinusitis?) Recurrent Acute Bacterial Sinusitis Recurrent Acute Bacterial Sinusitis • Diagnostic criteria (AAP CPG 2013) – – – – Meet criteria for ABS <30 days duration >10 symptom-free days in between episodes >4/year • Treatment – Same as ABS • Ask about kids • Referral for Evaluation – Atopy – Immune defects – Imaging for anatomy ABS Complications Sinus Development • Maxillary Sinus – Present at birth – 0-3, 6-12 yrs • Ethmoid Sinus – Present at birth – 0-12 yrs • Sphenoid Sinus – 3-14 yrs – Variable • Frontal Sinus – 7-adult – 5% aplastic Anatomy Lamina Papyracea (“paper-thin” bone) Sinus mucosa Periorbita Sinus Anatomy: Implications • Orbital complications most common – Ethmoid>frontal>maxillary • Most complications related to ethmoid sinus – Present at birth • Frontal sinus related complications more common in older children • Sphenoid complications rare but serious – Cavernous sinus/optic nerve Orbital Anatomy Orbital Infection: Chandler Classes Orbital Cellulitis Preseptal Cellulitis Postseptal Cellulitis • Periorbital redness/swelling • Periorbital redness/swelling • Eye itself looks fine • Eye not normal – No redness or chemosis – Redness or chemosis or diplopia • Normal EOM • EOM restricted – Not painful – Often by pain • Normal VA and Pressure • VA/Pressure +/- normal Unknown Microbiology of Cellulitis 00000098 Unknown What about MRSA 14 of 25 Staph A Cultures grew MRSA=56% Preseptal Cellulitis • Imaging not necessary initially • Treatment for ABS – Augmentin – ±decongestant – ±topical steroid • *Close follow-up (24 hour return?) • Majority of cases Cellulitis: When to send to ED? • Anything that might be postseptal cellulitis/abscess • • • • • • Eye itself at all abnormal Fever Severe lid swelling limiting exam Ophthalmoplegia Diplopia or EOM restriction Proptosis • Worsening or failure to resolve • Formal Ophtho exam • VA, IOP, EOM, etc • Imaging (CT scan of sinuses/orbit with contrast) • IV Abx Take Home Points • Separate baseline symptoms from discrete episodes via directed history • Educate patient on typical viral course and when to call/present for antibiotics • Appropriately prescribe antibiotics – Based on sxs and time course – Less azithromycin • Utilize SNAPs when patients push for abx • Refer to Otolaryngologist – >3-4 episodes of ABS/year – Complications – Failure to resolve to baseline after treatment Possible Courses Back to Baseline (normal) ABS Treatment Back to Baseline then Recurrence (recurrent acute sinusitis?) Fails to Resolve (subacute sinusitis or chronic sinusitis?) Subacute Sinusitis Chronic Rhinosinusitis (chronic sinusitis) Early Concepts of CRS-Plumbing problem Inciting event (virus/allergy/acute sinusitis) Swelling of sinus ostium/outflow Mucus stasis in sinus Bacterial sinus infection • Opening “blocked” sinus would break cycle and “fix” problem • Antibiotics +/- steroids +/-allergy Rx • Sinus surgery if above failed Newer Concepts of CRS-Chronic Inflammatory problem Abnormal host/environmental interaction Diffuse inflammation of mucosa (including ostia) Mucus stasis in sinus +/-Bacterial sinus infection • Bacteria may/may not play a role • Opening “blocked” sinus alone does not necessarily “fix” the problem • Steroids +/- antibiotics +/- allergy rx • Sinus surgery if above failed CRS Diagnosis • AAOHNS (2007) and EPOS (2012) Guidelines* – 12 weeks – Symptoms (must have 2) • • • • Nasal obstruction/congestion --84% Purulent drainage --64% Facial pain/pressure/fullness --65% Decreased smell --49% – Objective signs of inflammation • Edema/purulence • Polyps • Radiographic changes • 10-15% of US/Europe population • Symptoms only criteria is sensitive but lacks specificity *Rosenfeld et al. Otolaryngol Head Neck Surg 2007. Fokkens et al. Rhinology 2012. CRS Epidemiology CRS Epidemiology: Europe Overall=10.9% Range: 6.9-27.1% Symptoms only CRS Epidemiology: US • Number of noninstitutionalized adults with diagnosed sinusitis: 28.5 million • Percent of noninstitutionalized adults with diagnosed sinusitis: 12.1% • Patient report of a physician diagnosis • But does “sinusitis”=CRS? CRS Epidemiology: US 11.7 million visits/yr 1.1% all visits ICD: 473 CRS Impacts Burden of Disease What’s the big deal about a little chronic sinusitis? I would rather have sinusitis than _____________? Utility Values 0 Death • • • • 1 Perfect Health Used to derive QOLY in cost-effectiveness analysis Not as simple as asking for number (time trade off) Individual vs societal values Allows comparison across disease states Utility Values in CRS *Soler, Wittenberg, Schlosser, et al. Laryngoscope 2011. Burden of Disease Rhinologic Symptoms Extrarhinologic Sxs Focus has always been on cardinal rhinologic symptoms Have we under-appreciated extra-rhinologic symptoms? Sleep, fatigue, and cognitive dysfunction driving treatment decisions Sleep, fatigue, and cognitive dysfunction correlate most strongly with overall health states scores PSQI Scores 10 9.4±4.4 9.3±4.2 9 8.4±3.2 8 7 6.3±3.4 6 5 4 3 2 1 0 Chronic Rhinosinusitis OSA Narcolepsy Community 75% of CRS cohort with score ≥5 indicating “poor” sleep quality Simple Reaction Time Differences persist after controlling for age, gender, education, race/ethnicity, asthma, allergic rhinitis, OSA, and antihistamine usage Strong trend seen for Procedural Reaction Time and Matching to Sample tests Classification of CRS CRS Classification • CRS is a heterogeneous group of disorders • Current classifications – Presence of polyps • CRS with polyps (CRSwNP) • CRS without polyps (CRSsNP – Identifiable clinical factors • • • • Allergic fungal rhinosinusitis (AFRS)—Bent Kuhn Criteria Aspirin exacerbated respiratory disease (AERD) Fungal ball Mucocele – Histopathology or cytokine profile • Mucosal eosinophils • Endotyping CRS in its infancy *Fokkens et al. Rhinology 2012. Soler et al. Otolaryngol Head Neck Surg 2010 CRS with polyps (CRSwNP) • • • • Th-2 skewed inflammatory profile More mucosal eosinophilia Higher association with asthma/atopy Includes: – AERD – AFRS – Cystic Fibrosis • Nasal obstruction and loss of smell common • Chronic inflammatory condition with occasional bacterial exacerbation *Fokkens et al. Rhinology 2012. Soler et al. CRS without polyps (CRSsNP) • • • • Mixed Th-1/Th-2 inflammatory profile Less mucosal eosinophilia Less association with asthma/atopy Includes: – – – – Fungal ball Silent sinus syndrome Mucoceles Odontogenic sinusitis • Pressure/fullness and discharge common • Chronic inflammatory condition with perhaps more frequent bacterial contribution *Fokkens et al. Rhinology 2012. Soler et al. CRSwNP Medical Treatment Treatment EPOS12 EBBR Topical steroids A+ Recommended Oral steroids A+ Recommended Oral antibiotics C+ Option Macrolide C+ Option Saline irrigation D+ Recommended Antihistamines D+ -- Leukotriene ant D- Option Anti-IL5 D+ -- *Fokkens et al. Rhinology 2012. Soler et al. Topical Nasal Steroids RCTs only All double-blind, w/ITT Drops, sprays, turbuhaler 4-270 weeks duration Nasal congestion as primary outcome • All done in Europe • Success vs Failure • • • • • Forest Plot Steroid Type Take Home Message: • Steroid sprays definitely improve nasal obstruction/congestion in nasal polyps • No proven difference between steroid type • Most studies <6months • Experience tells us that improvement may be modest and erode over time Oral Steroids • • • • Parallel group RCT (3 arms) Group 1: Oral prednisolone 32à8mg/day for 20 days Group 2: Doxycyline 100mg/day for 20 days Group 3: Placebo for 20 days • Outcomes (12 weeks): Polyp grade, NPIF, nasal symptoms, inflammatory mediators Total Polyp Score • • • • • Parallel RCT 60 Adults with CRSwNP Group 1: 25mg/day oral prednisolone X 2 weeks Group 2: placebo X 2 weeks Both groups: Fluticasone drops X 8 weeks + fluticasone spray X 18 weeks • Outcomes: Polyp grade (primary), olfaction, QOL, nasal patency, adrenal fxn, bone turnover Take Home Message: • Oral steroids provide dramatic short-term improvement • Doxycycline likely has anti-inflammatory properties • Oral steroids are an important adjunct to topical steroid regimens—additive effect lasts 8-26 weeks CRSwNP Medical Treatment: • • • • Infrequent oral steroid bursts Topical steroid sprays PRN oral antibiotics if purulence If also have allergic rhinitis – Antihistamines – Leukotriene antagonists – SCIT—particularly AFRS • Anti-IL5 (?) • ASA desensitization Basic Algorithm Happy Topical steroid spray Pt Happy with Response Happy Unhappy CRSwNP Oral steroid taper + Topical steroid spray Late 6-8 weeks Oral steroid taper + Topical steroid spray Early Pt Unhappy with Response ESS ? Saline irrigations + Topical Spray ? Steroid irrigations CRSsNP Medical Treatment Treatment EPOS12 EBBR Topical steroids A+ Recommended Saline irrigation A+ Recommended Oral steroids C+ Option Oral antibiotics B+ Option Macrolide C+ Option Antihistamines -- -- Leukotriene ant -- -- *Fokkens et al. Rhinology 2012. Soler et al. Topical Steroids Oral Steroids Study Year Design LOE Ikeda et al. 1995 Case series 4 Subramanian et al. 2002 Case series 4 Hessler et al. 2007 Case series 4 Lal et al. 2009 Case series 4 Antibiotics *No placebo-controlled RCTs in CRSsNP CRSsNP Medical Treatment: • Oral antibiotics X 3 weeks if purulence – Broad spectrum – Culture-directed • • • • Topical steroid sprays Saline irrigations +/- oral steroid taper If also have allergic rhinitis – Antihistamines – Leukotriene antagonists – SCIT When to Consider Surgery When to Consider Surgery • Meet criteria for CRS • Failed trial (s) ongoing medical therapy – May look very different for different patients – Moving target • Symptoms continue to be bothersome • >90% of time decision to pursue surgery is based purely on symptoms/QOL from patient perspective Endoscopic Sinus Surgery • What it is not: – “Scraping” – “Roto-rooting” – “A cure for CRS”? Goals: 1. Allow mucus to drain properly (plumbing) 2. Allow topical medications to actually reach diseased sinus mucosa • What it is: – Targeted opening of natural ostia – Removal of ethmoid partitions with diseased mucosa – Correction of anatomic abnormalities • Septal deviation • Enlarged turbinates – Allows improved “control” of CRS Endoscopic Sinus Surgery • Outpatient surgery • 1.5-3 hours • ~1 week out of work/physical activity • Typical course: • Risks* – Nose bleed---1% – CSF leak---0.17% – Orbital injury---0.07% • Follow-up – Mild-mod discomfort – Bloody/mucus drainage – Fatigue *Ramakrishnan VJ et al. Int Forum Allergy Rhinol 2012 – 1 week – 3 weeks Postsurgical Management Goals: 1. Allow mucus to drain properly (plumbing) 2. Allow topical medications to actually reach diseased sinus mucosa Outcomes of Sinus Surgery • • • • • 2009, prospective study 1459 patients across UK Endoscopic sinus surgery CRSsNP and CRSwNP 3, 12, 36, and 60 months MCID MCID Utility Change with Treatment MCID Take Home Message: • Sinus surgery improves specific sxs and general QOL • Most patients get clinically significant improvement • Concept of “control” rather than “cure” Take Home Message: CRS is a heterogeneous group of disorders Medical management varies based on polyp status Endotype may ultimately guide treatment Consider surgery when remains symptomatic despite medical regimen • Endoscopic sinus surgery • • • • – Improves drainage – Improves access for topical medications • Concept of “control” rather than “cure”