fourth annual ent for the pa-c | april 24-27, 2014 ... - chronic rhinoinusitis - ferguson.pdffistula...

3/18/2014

1

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Chronic Rhinosinusitis Subcategories and unusual manifestations of

systemic disorders.BJ Ferguson MD

Director Division of Sino‐nasal Disorders and Allergy

University of Pittsburgh


Disclosure

• Teva: Advisory Board

• Meda: Advisory Board

• Integrity: CME speaker

• Sanofi Aventis: Research – Industry sponsored Phase III trial


Learning Objectives

• Describe Chronic Rhinosinusitis and its subcategories, discussing diagnosis and management.

• Identify the role and evaluation of eosinophilicdisease in Chronic Rhinosinusitis.

• Recognize the unusual manifestations of systemic disease in the nose such as Wegener’s and narcotic abuse.

3/18/2014

2


Categorizing CRS

No Nasal polys

• Odontogenic

• Pyogenic

• Anatomic

With Nasal Polyps

• With Eosinophilia

– AFS

– AERD

– Food Hypersensitivity

• Without Eosinophilia– Cystic Fibrosis

– Antral Choanal Polyp


Boring through the alveolus after excavation of a tooth (Cowper method)

• After extraction of the offending tooth, (usually second premolar or first molar)

• Pledglet of cotton saturated with a 20% solution of cocaine packed into the cavity for 10 minutes

• A large dental drill or a guarded Hartmann borer is now used to make an opening into the sinus.

Skillern , 3rd ed 1920


Must be recognized in order to be treated effectively

• I recommended extraction Rt. Rear molar

• Repeat Dental consult: “no dental pathology”

• Patient and I insist on dental extraction

• Tooth extracted

• No recurrence x 1 year

3/18/2014

3

July 2010: telephone consult

advice on patient with sinus CT showing right max, frontal sinusitis.

She is on MTX for RA and has been sx x 7 months, failed course of augmentin

Microbiology of intracranial abscesses associated with sinusitis of odontogenic origin.Brook I.Ann Otol Rhinol Laryngol. 2006 Dec;115(12):917‐20


2013 Management of OMS

Resolve dental infection Root canal or extractionCan try office irrigation and antibiotics

Culture frequently negative

If no subsequent resolution, ESS with irrigation

If anticipate Oral‐Antralfistula with extraction then concomitant ESS and repair

Between 1995 and 2010: 11 of 85 (13%) sinus guidelines specifically mentioned odontogenic

maxillary sinusitis (OMS)

Longhini A, Ferguson BJ: Clinical Aspects of OMS: a case series, IFAR 2011

3/18/2014

4


Anatomic causes

• OMC obstruction

• Unusual from orbital decompression for Graves


Maxillary sinus tap

• Same patient, 3 days preop, decompressed with inferior meatal tap

• Video of antral tap


Mimics and Comorbidities of CRS

• Migraine

• CFS/fibromyalgia

• Allergic rhinitis

• OSA

• GERD

3/18/2014

5

CRS + (n=75) and CRS neg (n=50)

CRS + CT sx > CRS nl CT

CRS nl CT sx> CRS + CT

.01

Ferguson et al: CID 2012Prospective observational study of CRS


Ferguson et al: CID 2012Prospective observational study of CRS

• 30% of CT+CRS had endoscopic purulence

• 0% of CT‐ CRS had endoscopic purulence

• Both groups reported similar antibiotic use and response to therapy – 50%


PPI therapy Improves symptoms of “PND” Vaezi M; gastroenterology 2010

• BRPCT

• Nl sinus CT

• Negative allergy testing

• PPI x 16 weeks vs placebo

• Significant improvement in PND sx at 8 weeks and 16 weeks

• No GI/reflux test predictive of response

3/18/2014

6

OSA, recumbent nasal blockage, GERDand the ANS a unifying hypothesis

Normal Sleep

GERD VMR (nasalcongestion)

OSA

Parasympathetic same ↑ same Same or ↓

Sympathetic ↓ same ↓ ↓↓

Para/sympathetic > 1 >1 >1 >1

Jaradeh, Smith et al Laryngoscope 2000

Theory: ANS impacts multiple disorders which may in turn influence

comorbidities

Parasympathetic > Sympathetic

ANS dysfunction

Treatment

• VMR and Recumbinantcongestion

– oxymetazolin with NSS

– Turbinate reduction

– Ipratrobium nasal spray

• OSA– positive pressure, IX nerve

stimulation

• GERD– Proximal Vagotomy

Baseball in style at Miller Park

3/18/2014

7


Allergies and Sinusitis: the Rational Patient Experimenta practical method for best treatment of nasal symptoms

regardless of cause.

Sitska, Alaska 8/2012

20

Learning Objectives• Formulate a logical management plan for patients with allergic rhinitis (AR) or Chronic Rhinosinusitis (CRS) according to available evidence‐based clinical guidelines MAKE ALLERGY /NASAL CARE EASY

• Recognize the symptoms of AR and CRS and understand impact upper airway can have have on the lower airway “unified airway” Asthma and CRS / AR coexist

• Describe the characteristics of available therapeutic options for patients with AR and CRS

• Implement strategies to improve treatment adherence while considering patient preferences for therapy

Diagnosing by SymptomsAllergic rhinitis Non allergic rhinitis CRS

congestion + + +

Drainage PND + + +Facial pain and pressure

+ + +

rhinorrhea + + +cough + + +sneezing + +Nasal itch + +/‐Upper teeth pain 40% dental

infections

Rotten odor 50% of dental sinusitis

Decreased smell +/‐ +/‐ Majority of nasal polyp

3/18/2014

8


Medications approved by Indication

• Allergic rhinitis (SAR, PAR): antihistamines (oral and topical), antihistamines/decongestants, nasal steroid sprays, leukotriene modulators (montelukast)

• Nonallergic Rhinitis: none for > 10 years, FDA changed criteria for indication. Some steroid sprays and azelastine

• Chronic Rhinosinusitis: nasal steroid sprays for nasal polyps


How often is CRS substantiated by an abnormal sinus CT scan?

• Up to 30% of asymptomatic patients have some abnormality of sinuses on CT

• 40% of patients with strong litany of CRS symptoms x 3 months have normal sinus CT

• Sinus CT is a “picture in time” and is abnormal in 80% of patients with a cold, however in 2 weeks these changes are much improved


Allergic Rhinitis: Targeted Symptom Relief

Nasal congestion

Sneezing Nasal itching

Eye Sx

Rhin-

norrhea

Nasal Steroid +++ +++ +++ + +++Antihistamines 1st

2nd

+/-

+/- *

++

++

++

++

++

++

++

-

Decongestants +++ - - - -

Ipratropium - - - - +++Mast Cell Stablizer

+ + + +/- +

LTR ++ + + + +* Azelastine has +++ decongestive properties

3/18/2014

9

What is the Rational Patient Experiment?

• In an experiment, one variable is changed to observe whether it changes the out come of the experiment

• The outcome is: “How do your nose/sinus symptoms feel; how do you feel?”

• The Variable is the Medication or Intervention

• Each pharmacologic intervention is tried one at a time

Snow fall in Pride’s Crossing, MA Jan 2009

Rational Patient Experiment


RPE: Instructions•

Our goal is to relieve your nose and sinus problems with the fewest number of medications. People respond differently to medicines and we will not know which medicine works best for you, or even causes a side effect, without doing an experiment.

The RATIONAL PATIENT EXPERIMENT: Try each checked medicine ONE AT A TIME.

If the medicine does NOT make you feel better in 3 to 4 days then STOP the medicine and try the next medicine listed.

If the medicine makes you feel PARTIALLY better, but not completely symptom free, then ADD the next medicine listed to the medicine that was partially helping you.

If the medicine RELIEVES your symptoms, then CONTINUE it for at least several days or weeks. If you are feeling back to normal, then stop the medicine, but restart it if your symptoms start to return.

3/18/2014

10


EMRS (n=69) vs. AFS (n=431)

0102030405060708090

100

AGE Male (%) Polyps (%) UnilateralDz(%)

EMRSAFS

*P<.001 # P<.00001

* #

Eosinophilic CRS multiple often overlapping causes

.

Spector SL. J Allergy Clin Immunol. 1997;99:S773‐S780.

AERD

Eosinophilic CRS

Nasal Polyposis?

+ food allergies

Super antigen IGE mediated

FungusAFS

ChurgStrauss

Asthma


Categorization of Eosinophilic CRS

1. Fungus “allergic fungal sinusitis”a. TLR4 Independent(classic)

TLR4 Dependent triggered by coagulation byproducts induced by fungal or other proteases Science 2013; NEJM 11/2013

2. Bacteria – “Superantigen”3. Food Hypersensitivity4. Aspirin Exacerbated

Respiratory Disease5. Eosinophilic Vasculitis

(Churg‐Strauss Syndrome)

b.

3/18/2014

11

Spectrum of Fungal SinusitisImmunologic Spectrum

compromised competent ? Allergic

Invasive-acuteMucor

Aspergillus

Fusarium

Pseudallescherii

Chronic

invasiveFungus

Balls

Aspergillus

NA EFRS AFSBipolaris

Aspergillus

Curvularia

Alternaria

Saprophytic fungus


N.P. A 42 year old woman with a 6 month history of worsening headaches and scant discolored drainage is admitted through the ER

• multiple courses of antibiotics over last 6 months ‐ no improvement

• IDDM – in moderate control

• Renal transplant 2 years earlier

• ESS to remove fungus ball 10 years earlier

• PE: in moderate distress because of pain

• Temp: 37.9 C

• Without cranial neuropathy


Sinus CT on Admision

3/18/2014

12


What do you do next?

A. IV Clindamycin, Rifampin and Gentamicin

B. MRI

C. urgent ESS with debridement

D. Amphotericin B


Mimics of AFS ‐ EMRS

AFS: fungi present in eosinophilic mucin with IgE mediated allergy to cultured fungus

No fungal allergy, no fungus on path just eosinophilic mucin


Allergic Fungal Sinusitis versus Eosinophilic Mucin Rhinosinusitis

without Fungus (AFS – Like)Ferguson, BJ; Laryngoscope 2000

431 AFS total cases

418 literature

13 personal series

69 EMRS total cases

40 from literature

29 personal series

Toulouse ARS 2012

3/18/2014

13

Therapeutic Implications – AFS vsAFS‐like or EMRS

AFS EMRS

Surgery + +

Steroids + +

Nasal lavage + +

Antifungals + -

Immunotherapy + -

Omaluzumab ? Superantigen


1999‐2006 Ponikau and the Anti fungal controversies

• 98% of CRS patients with fungus• 70% improved with amphotericin irrigations, non

randomized trial• Wechta DBRCT: no difference between saline lavage and

amphotericin, excluded AFS, but 3 patients had 50% improvement on CT in Amp arm and none on Placebo

• Ebbens DBRCT: definitive study, NO difference amphotericin irrigations or placebo

• But study has not been done in just AFS patients, especially post op

Antifungal washes cure most CRS, because fungus is everywhere and so are eosinophils; 1999 Ponikau

Balloons cure sinus disease because theyatraumatically enlarge the sinus ostia

3/18/2014

14


“The obstacle to discovery is not ignorance,it is the illusion of knowledge” Dan Boorstin

• Best Evidenced Based Review is EPOS 2012

• For CRS only saline irrigations and topical steroids show efficacy.

• No evidence for antibiotics, antifungals

• Future: targeted agents like duplizumab (anti IL4 receptor)

Hana no hana “nose flowers”Colorized TEM of nasal epithelium and cilia


Can Elimination Challenge Food Diets Help?

• Prospective collection of data on CRS patients undergoing ECFD

• 43 Adults with CRS: 21 without nasal polyps, 22 without

• Intervention: Completion of QoLsurveys, nasal endoscopy, allergy testing, ECFD

• 49% reported improvement in sinonasal symptoms

• 22% reported increased energy, decreased abdominal symptoms


Elimination Challenge Food Diet

• Take food out of diet x 5 to 10 days, then ingest and monitor for symptoms for next 24 hours.

3/18/2014

15


Can Elimination Challenge Diets Help?

• Most commonly reported food was wheat (43%) followed by dairy (28%), or both 14%

• Endoscopic improvement in 24%

• 33% of responders had positive allergy testing

• Only 9% aware of food allergies prior to office visit


UNUSUAL CAUSES OF CHRONIC RHINOSINUSITIS (CRS)

• VASCULITIC– CHURG STRAUSS

(EOSINOPHILIC VASCULITIS)

– LUPUS– Granulomatosis with

polyangiitis (GPA) formerly known as WEGENER’S GRANULOMATOSIS

• GRANULOMATOUS– SARCOID– RHINOSCLEROMA

• Other – Intranasal abuse with

oxycontin or acetomenophin


Vasculitic Causes of CRS• Granulomatosis with polyangiitis (GPA) used to be known as Wegener;sGranulomatosis

• Renal, Pulmonary and Upper Airway

• Nasal bleeding and septal perforation

• Elevated cANCA, WSR,

• Path: granulomas and vasculitis

3/18/2014

16


Sarcoid

• Early: submucosalmasses along septum

• Later: sticky mucus crusting with bacterial colonization

• Occasionally perforation

• Dx: usually bx with noncaseatinggranulomas


Eosinophilic VasculitisChurg strauss syndrome

1. Allergic stage: 90% have asthma 3 to 5 years prior to dx

2. Eosinophilic stage: hypereosinophilia;

3. Vasculitic Stage: GI , cardiac (1/2 of deaths)

• Diagnosis 4/6 criteria

– pANCA

– Asthma

– >10% Eosinophilia

– Neuropathy

– Pulmonary infiltrates

– CRS

– Extravascular E’s


Conclusion and a few additional pearls

• CRS symptoms x 12 weeks, sx are nonspecific– Decreased smell– Drainage– Congestion– Facial pressure

• Initially Rational Patient Experiment– Saline nasal washes– Nasal Steroid Spray– If purulent – culture,

nasopharyngeal swab surrogate for sinus

• CT scan if impending complication– Cone Beam CT less radiation

• Only get CT if it will change therapy or if ESS planned

• Usually after endoscopic evaluation and management and persistence

3/18/2014

17


Summary

• Only Level 1 evidence for topical steroids and saline washes

• No good evidence for antibiotics (culture directed studies not done)

• Dental cause (maxillary), rotten smell, sometimes tooth pain

• May require CT for diagnosis


Thank you

fourth annual ent for the pa-c | april 24-27, 2014 ... - chronic rhinoinusitis - ferguson.pdffistula...

Documents