sinusitis: what the primary care practitioner should do in 2011: a review of new canadian guidelines...

SINUSITIS: What the PrimaryCare Practitioner Should Do in 2011:

A Review of New Canadian Guidelines

SINUSITIS: What the PrimaryCare Practitioner Should Do in 2011:

A Review of New Canadian Guidelines

Martin Desrosiers, MD FRCSCProject Lead: Canadian Guidelines in Sinusitis Project

Clinical ProfessorUniversité de Montréal

Montréal, Quebec, Canada

Learning ObjectivesLearning Objectives

1. Present burden of disease, diagnosis & classification of acute rhinosinusitis

2. Review data that pertains to a new way of treating acute rhinosinusitis

3. Review guidelines and future implications

4. Become familiar with the Canadian Clinical Practice Guidelines Committee recommendations for diagnosis and treatment of acute and chronic rhinosinusitis

Management of Acute Rhinosinusitis

A Paradigm in Evolution

Management of Acute Rhinosinusitis

A Paradigm in Evolution

Management of Sinusitis: 1991 – 2010Management of Sinusitis: 1991 – 2010

1997

• Emphasis on differentiation between bacterial and viral sinusitis– ABRS as a clinical diagnosis

• Standardized diagnostic criteria• X-ray rarely required

– First-line therapy: Amoxicillin

– Duration of therapy: 10-14 days

Low DE, Desrosiers M, et al. Can Med Assoc J. 1997; 156: S1-S14.

Evolving issues in ABRSEvolving issues in ABRS

•Role of antibiotic therapy in ABRS is being questioned

– Recognition that URTI represent high % of episodes of ABRS

– Spontaneous improvement without antibiotics

– Complications of antibiotic therapy recognized• Individual (Colitis etc.)• Societal (Resistance)

•Suggests need for alternate therapy for management of ABRS

Case 1: Uncomplicated Acute Bacterial RhinosinusitisCase 1: Uncomplicated Acute Bacterial Rhinosinusitis

•Previously healthy 32-year-old non-smoking mother

•Recent onset of symptoms of an upper respiratory tract infection (URTI)

– Persistent nasal obstruction

– Right-sided maxillary facial pain

– Yellowish secretions

•Have all lasted 9 days from onset

•Has not responded to over-the-counter medication

Physical ExaminationPhysical Examination

• No apparent distress

• Yellowish secretions in right middle meatus

• Tenderness of her right maxillary sinus area on palpation

AssessmentAssessment

•Typical symptoms of 7 days duration strongly suggest bacterial rhinosinusitis

– No x-ray is required to confirm diagnosis

•Symptom intensity is mild to moderate

•No signs of complications or systemic toxicity

QuestionQuestion

•Diagnosis: Uncomplicated mild-moderate acute presumed bacterial sinusitis

•Are antibiotics required for management?

Rhinosinusitis:

Disease or Simple Nuisance?

Rhinosinusitis:

Disease or Simple Nuisance?

Respiratory Infections Are the # 1 Reason for Office VisitsRespiratory Infections Are the # 1 Reason for Office Visits

Therapeutic ProfileTherapeutic Profile

ARS Impairs QOLSF-36 Descriptive Stats: Bodily PainARS Impairs QOLSF-36 Descriptive Stats: Bodily Pain

Impact of CRS on PatientsImpact of CRS on Patients

•More bodily pain and worse social functioning than patients with chronic obstructive pulmonary disease, congestive heart failure or back pain

•Quality of life is comparable in severity to that of other chronic conditions

•As a chronic condition, CRS should be proactively managed

•CRS is an inflammatory disease involving the nasal mucosa and paranasal sinuses

•Symptoms are usually of lesser intensity than those of ABRS

•Length of episode > 4 weeks

Gliklich RE, et al. Otolarygol Head Neck Surg. 1995;113:104-109.

Nearly Two-thirds of All Oral Solid Antibiotic Prescriptions Are for Sinusitis and BronchitisNearly Two-thirds of All Oral Solid Antibiotic Prescriptions Are for Sinusitis and Bronchitis

Does the World Need More Guidelines?Does the World Need More Guidelines?

•Canadian focus– Canadian incidence, socioeconomic, QOL data– Factors in Canadian issues (e.g. wait times for CTs)

•Addresses CRS, an area where controversy is unresolved and evidence is less with incorporation of expert opinion based on pathophysiology and current treatment regimens (Grade D)

Preparing a Complete Document for the Management of SinusitisPreparing a Complete Document for the Management of Sinusitis

• Principal thrust is a comprehensive guide to CRS and to address changes in the management of ABRS

• Practical focus: Directed at first-line practitioners with emphasis on patient-centric issues (e.g. facial pain NOT sinusitis)

• Involvement of multiple stakeholders for multidisciplinary input

• Brief, easily readable

AGREE InstrumentAGREE Instrument

•Objectives clearly stated

•Target population indentified

•Stakeholders included in development

•Recommendations specific

•Additional educational materials

•Monitoring of uptake

•Regular revision

The AGREE Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument.Available at: www.agreecollaboration.org.

What’s New?What’s New?

Acute Bacterial Rhinosinusitis 2011Acute Bacterial Rhinosinusitis 2011

A Major Change in Attitude

•Previously, emphasis on differentiating viral rhinosinusitis from acute bacterial sinusitis– Antibiotic therapy mandatory for all cases of ABRS

•Questions regarding efficacy of antibiotic therapy lead to new recommendations– Assess severity of sinusitis– Option of no antibiotic therapy for mild-to-moderate– Intranasal corticosteroids (INCS) as sole therapy without antibiotics

When is Sinusitis Mild? Rating the Severity of ABRSWhen is Sinusitis Mild? Rating the Severity of ABRS

When to Order an Antibiotic?Rating the Severity of ABRSWhen to Order an Antibiotic?Rating the Severity of ABRS

Chronic Rhinosinusitis (CRS)Chronic Rhinosinusitis (CRS)

• A complex disease with variable clinical presentations

• Inflammatory condition of the sinonasal mucosa interacting with

bacterial and/or fungi

• More than 10% of individuals in western countries affected*

• Genetic and environmental triggers likely play a significant role in

pathogenesis

*Bachert C, et al. Allergy. 2003;58:176-191.

Chronic Rhinosinusitis: New for 2011Chronic Rhinosinusitis: New for 2011

•Emphasis on role of inflammation in the pathogenesis of CRS

•Distinction between CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP)

•Management strategies for the Primary Care Provider

•Indications for referral

•Management of the post-surgical patient

Statements: Summary

Canadian Rhinosinusitis Guidelines 2011

Acute Bacterial Rhinosinusitis

Statements: Summary


Acute Bacterial Rhinosinusitis

Summary of Guideline Statements: ABRS (1 of 4)Summary of Guideline Statements: ABRS (1 of 4)

Strength of evidence integrates the grade of evidence with the potential for benefit and harm. Strength of recommendation indicates the level of endorsement of the statement by the panel of experts.

Statements: Summary


Chronic Rhinosinusitis

Statements: Summary


Chronic Rhinosinusitis

Summary of Guideline Statements: CRS (1 of 3)Summary of Guideline Statements: CRS (1 of 3)

Strength of evidence integrates the grade of evidence with the potential for benefit and harm. Strength of recommendation indicates the level of endorsement of the statement by the panel of experts.

Acute Bacterial RhinosinusitisAcute Bacterial Rhinosinusitis

ABRS: Definition and DiagnosisABRS: Definition and Diagnosis

•ABRS is a bacterial infection of the paranasal sinuses characterized by:– Sudden onset of symptomatic sinus infection– Symptom duration > 7 days– Length of episode < 4 weeks– Major symptoms (PODS)

• Facial Pain/Pressure/fullness• Nasal Obstruction• Nasal purulence/discoloured postnasal Discharge• Hyposmia/anosmia (Smell)

•Diagnosis requires the presence of > 2 PODS, one of which is either O or D and symptom duration of > 7 days without improvement.

ABRS: Diagnosis (cont’d)ABRS: Diagnosis (cont’d)

•Diagnosis is based on history and physical examination:– Sinus aspirates or routine nasal culture are not recommended– Radiological imaging is not required for uncomplicated ABRS– Because complications of ABRS can elicit a medical emergency,

individuals with suspected complications should be urgently referred for specialist care

•Red flags for urgent referral include:– Systemic toxicity– Altered mental status– Severe headache– Swelling of the orbit or change in visual acuity

ABRS: MicrobiologyABRS: Microbiology

•Main causative bacteria:– Streptococcus pneumoniae– Haemophilus influenzae

•Minor causative bacteria:– Moraxella catarrhalis– Streptococcus pyogenes– Staphylococcus aureus– Gram-negative bacilli– Oral anaerobes

ABRS: Role of AntibioticsABRS: Role of Antibiotics

•Antibiotics may be prescribed to improve rates of symptom resolution– Overall response rates are similar for antibiotic-treated and

untreated individuals

•Goal of treatment is to relieve symptoms by:– Controlling infection– Decreasing tissue edema– Reversing sinus ostial obstruction to allow drainage of pus

•Antibiotics should be considered for individuals:– With severe sinusitis or comorbidities– Where quality of life or productivity are issues

•Incidence of side effect mainly digestive, increases with antibiotic administration

ABRS: Implications of Antibiotic ResistanceABRS: Implications of Antibiotic Resistance

•There are increasing rates of antibiotic resistance– Penicillin- macrolide- and multi-drug resistant– S. pneumoniae in community-acquired respiratory tract infections

•Be cognizant of local patterns of antibiotic resistance as regional variations exist

•Medical history influences treatment choice

•Identify patients at increased risk of bacterial resistance and complications– Those with underlying disease (eg diabetes, chronic renal failure,

immune deficiency)– Those with underlying systemic disorders

ABRS: Considerations for Choosing an AntibioticABRS: Considerations for Choosing an Antibiotic

•Suspected or confirmed etiology

•Medical history

•Presence of complications

•Canadian patterns of antimicrobial resistance– Regional variations

•Risk of bacterial resistance

•Tolerability

•Convenience

•Cost

ABRS: Antibiotic ConsiderationsABRS: Antibiotic Considerations

•Factors suggesting greater risk of penicillin- and macrolide-resistant streptococci

– Antibiotic use within the past 3 months• Choose an alternative class of antibiotic from that used in the

past 3 months– Chronic symptoms greater than 4 weeks– Parents of children in daycare

•When prescribed, antibiotics should be taken for 5-10 days as recommended by the product monograph

– Improvement in symptoms without complete disappearance of symptoms at the end of therapy should be expected and should not cause an immediate prescription of a second antibiotic

ABRS: Choice of AntibioticABRS: Choice of Antibiotic

•First-line: amoxicillin– In beta-lactam allergy, TMP/SMX or macrolide

•Second-line: amoxicillin/clavulanic acid combination, or quinolones with enhanced gram positive activity

– For use where first-line therapy failed (no clinical response within 72 hours), risk of bacterial resistance is high, or where consequences of therapy failure are greatest (i.e. because of underlying systemic disease)

•For uncomplicated ABRS in otherwise healthy adults, antibiotics show comparable efficacy

ABRS: INCS as MonotherapyABRS: INCS as Monotherapy

•INCS may be explored based on limited evidence suggesting benefit– Promote drainage and reduce mucosal swelling

• Hasten resolution of sinus episode and clearance of infectious organisms

•No increased incidence of complications

ABRS: First-line Treatment FailureABRS: First-line Treatment Failure

•If symptoms do not at least partially attenuate by 72 hours after INCS administration– Administer antibiotic therapy

•If symptoms do not at least partially attenuate by 72 hours after antibiotic therapy– Bacterial resistance should be considered, and – Antibiotic class should be changed

• Switch to a second-line antibiotic (e.g. moxifloxacin or amoxicillin/clavulanic acid combination)

• In the case of a second-line failure, switch to another antibiotic class

ABRS: Adjunct TherapyABRS: Adjunct Therapy

•Adjunct therapy may provide symptom relief and should be prescribed in individuals with ABRS:– Topical intranasal corticosteroids (INCS)– Analgesics (acetaminophen or non-steroidal anti-inflammatory agents)– Oral decongestants– Topical decongestants– Saline irrigation

ABRS: Prevention and Contributing FactorsABRS: Prevention and Contributing Factors

•Prevention strategies aim to reduce the risk of acute viral infection (common precursor to ABRS)

– Techniques• Handwashing• Educating patients on common predisposing factors

•For patients with recurrent episodes of ABRS, consider underlying contributing factors

– Allergy testing to detect allergic rhinitis– In-depth assessment of immune function to detect immune deficiencies

Chronic RhinosinusitisChronic Rhinosinusitis

CRS: DefinitionCRS: Definition

•CRS is an inflammatory disease involving the nasal mucosa and paranasal sinuses

– Symptoms are usually of lesser intensity than those of ABRS– Length of episode > 4 weeks

•Impact on patients– Significant bodily pain and impaired social functioning– Quality of life is comparable in severity to that of other chronic

conditions– As a chronic condition, CRS should be proactively managed

CRS: PathophysiologyCRS: Pathophysiology

•Unclear origin, but contributors may include:– Bacterial colonization– Bacterial biofilms– Eosinophilic, neutrophilic, and lymphocytic infiltrations– Upregulation of the Th2-associated cytokines– Tissue Remodeling

• Epithelial changes• Increased extracellular matrix proteins• Growth factors• Profibrotic cytokines

•Atopy determines allergic vs. nonallergic classification

CRS: BacteriologyCRS: Bacteriology

•Bacteriology differs from ABRS

•Not well understood

•Main pathogens– S aureus– Enterobacteriaceae spp– Pseudomonas spp

•Less common pathogens– S pneumoniae– H influenzae– Beta hemolytic streptococci– Coagulase-negative Staphylococci (CNS)

CRS: DiagnosisCRS: Diagnosis

•Required > 2 major symptoms be present for > 8-12 weeks, plus documented inflammation of the paranasal sinuses or nasal mucosa

•Major symptoms:– Facial Congestion/ fullness– Facial Pain/ pressure/ fullness– Nasal Obstruction/ blockage– Purulent anterior/ posterior nasal Drainage (may be nonpurulent

nondiscoloured)– Hyposmia/ anosmia (Smell)

•Inflammation documented by endoscopy /CT

CRS: SubtypesCRS: Subtypes

CRSwN

Characterized by:– Mucopurulent drainage– Nasal obstruction– Hyposmia

Diagnosis requires:– At least 2 major symptoms– Bilateral polyps in the middle

meatus (endoscopy)– Bilateral mucosal disease

(CT scan)

CRSsNP

Characterized by:– Mucopurulent drainage– Nasal obstruction– Facial pain/ pressure/ fullness

Diagnosis requires:– At least 2 major symptoms– Inflammation (endoscopy)– Absence of polyps

(endoscopy)– Purulence from osteomeatal

complex (endoscopy) or rhinosinusitis (CT scan)

CRS: Visual AssessmentsCRS: Visual Assessments

•Physical examination of the nasal cavity using:– Headlight and nasal speculum– Otoscope

•In the nasal septum:– Identify drying crusts, ulceration, bleeding ulceration, and perforation,

anatomic obstructions, unusual aspects of the nasal mucosa and/or presence of secretions or nasal masses

– Note significant septal deflections, colour of the nasal mucosa and presence of dryness or hypersecretion• Normal mucosa is pinkish-orange with a slight sheen demonstrating

hydration– Presence of an irregular surface, crusts, diffusely hemorrhagic areas,

vascular malformations or ectasias, or bleeding in response to minimal

trauma, is abnormal and should warrant specialist assessment

CRS: Visual Assessments (Cont’d)CRS: Visual Assessments (Cont’d)

•In the inferior turbinates– Assess for hypertrophy

•In the middle meatal area– Inspect the area of the middle turbinate and the middle meatus

adjacent between the septum and the lateral nasal wall for the presence of secretions or masses (e.g. nasal polyps)

– Visualization may be improved by performing• Vasoconstriction using a decongestant product (e.g. Dristan®

or Otrivin®)• Sinonasal endoscopy

CRS: Specialist ReferralCRS: Specialist Referral

•Referral to a specialist is warranted when a patient:– Fails > 1 course of maximal medical therapy or,– Has > 3 sinus infections per year

•URGENT consultation with otolaryngologist required if patient:– Has severe symptoms of pain/ swelling of the sinus areas or,– Is immunosuppressed

•Allergy testing– Identify allergic components that might respond to allergy

treatment ( e.g. avoiding environmental triggers, or taking appropriate pharmacotherapy or immunotherapy)

•Immune function testing– Not required in uncomplicated cases– May be appropriate for patients with resistant CRS

CRS: Environmental FactorsCRS: Environmental Factors

•Both environmental and physiologic factors that can predispose to, or be associated with CRS– Allergic rhinitis– Asthma– Ciliary dysfunction– Immune dysfunction– Aspirin-exacerbated respiratory disease– Defective mucociliary clearance– Lost ostia patency– Cystic fibrosis

CRS: General Management StrategiesCRS: General Management Strategies

•Identify and address contributing or predisposing factors

•Oral or topical steroids with or without antibiotics– Antibiotic therapy should be broader spectrum than for ABRS

• Empiric therapy should target enteric Gram-negative organisms, S aureus and anaerobic in addition to the most common encapsulated organisms associated with an ABRS (S pneumoniae, H influenzae, M catarrhalis)

– Antibiotic therapy duration tends to be slightly longer than for ABRS

CRS: Initial Management is MedicalCRS: Initial Management is Medical

•In the absence of complication or severe illness– CRSsNP: nasal or oral corticosteroid and oral antibiotics– CRSwNP: topical intranasal steroids and short courses of

oral steroids• Simultaneous oral antibiotic therapy indicated only in the

presence of symptoms suggestion infection (e.g. pain or recurrent episodes of sinusitis, or when purulence is documented on rhinoscopy/endoscopy

CRSsNP: TreatmentCRSsNP: Treatment

•INCS should be prescribed for all patients– Benefits include addressing the inflammatory component of CRS

•Antibiotics with or without a short course of oral steroids should be prescribed at the initiation of therapy

•Ancillary measures such as saline irrigation my be of help

•A short course of oral corticosteroids my be required for more severe symptoms or persistent disease

CRSwNP: TreatmentCRSwNP: Treatment

•INCS are the mainstay of therapy– Benefits include

• Addressing the inflammatory component of CRS• Relieving nasal congestion• Shrinking nasal polyps

•A short course of oral steroids may be prescribed in symptomatic subjects– A 2-week course of prednisone may reduce polyp size in patients

unresponsive to INCS– Leukotriene receptor antagonists may warrant a trial especially in

patients with ASA sensitivity– Combined therapy with empiric or culture-directed antibiotics are

indicated in the presence of symptoms suggestion infection

CRS: Adjunct TherapiesCRS: Adjunct Therapies

•Approaches with consistent evidence of benefiting symptoms– Saline irrigation

•Approaches with limited evidence of benefiting symptoms– Mucolytics– Antihistamines– Leukotriene modifiers

CRS: Alternate DiagnosisCRS: Alternate Diagnosis

•Failure of response should prompt consideration of other possible or contributing diagnoses– Allergic fungal rhinosinusitis– Allergic rhinitis– Atypical facial pain– Invasive fungal rhinosinusitis– Migraine or other headache diagnosis– Nasal septal deformation– Nonallergic rhinitis– Temporomandibular joint dysfunction (TMG)– Trigeminal neuralgia– Vasomotor rhinitis

CRS: Endoscopic Sinus Surgery (ESS)CRS: Endoscopic Sinus Surgery (ESS)

•Indicated for patients who fail maximal medical therapy

•Provide specialist referral for assessment of disease

•The goals of ESS are to:– Clear diseased mucosa– Relieve obstruction– Restore ventilation

CRS: Post-surgical Follow-upCRS: Post-surgical Follow-up

•Immediate postoperative care involves antibiotics, topical/oral corticosteroids and saline irrigation

•Monitor patient for severe symptoms of pain, fever, or new-onset coloured secretions– Immediately refer to operating surgeon

•Continued care includes nasal saline irrigation and INCS with limited evidence

•CRS patients with high peripheral eosinophil counts, asthma, or mucosal eosinophil CRS should be followed closely and may require long-term treatment with anti-inflammatory agents (steroids)

Guidelines for the Management of ABRS and CRS

ABRS Algorithm


ABRS Algorithm

Management of ABRS (1 of 2)Management of ABRS (1 of 2)

Management of ABRS (2 of 2)Management of ABRS (2 of 2)


Chronic Rhinosinusitis Algorithm


Chronic Rhinosinusitis Algorithm

Management of CRS (1 of 2)Management of CRS (1 of 2)

Management of CRS (2 of 2)Management of CRS (2 of 2)

Case Studies in RhinosinusitisCase Studies in Rhinosinusitis

Case 1: Uncomplicated Acute Bacterial RhinosinusitisCase 1: Uncomplicated Acute Bacterial Rhinosinusitis

•Previously healthy 32-year-old non-smoking mother

•Recent onset of symptoms of an upper respiratory tract infection (URTI)– Persistent nasal obstruction– Right-sided maxillary facial pain– Yellowish secretions

•Have all lasted 9 days from the outset

•Has not responded to over-the-counter medication

Nasal Examination: PurulenceNasal Examination: Purulence

AssessmentAssessment

•This case suggests bacterial rhinosinusitis

•The presence of several typical symptoms accompanied by duration of symptoms for greater than 7 days, strongly supports this diagnosis

•Given the weight of evidence in favour of the clinical diagnosis of bacterial sinusitis, no x-ray is required to confirm diagnosis

•Symptom intensity is mild to moderate and there are no signs of local complications or of systemic toxicity

ManagementManagement

•Uncomplicated episode of bacterial sinusitis

•Symptoms are mild to moderate only– Therapy with an antibiotic is not mandatory

•Options for management include– Continuing her topical saline– Oral or topical decongestants– Analgesia for pain– Use of mometasone furoate

Are Antibiotics Required?Are Antibiotics Required?

•If INCS are not efficacious– Amoxicillin 500 mg TID– Macrolide for penicillin-allergy

•Symptoms are expected to improve, but not to resolve completely, within 72 hours

Second-line Therapy?Second-line Therapy?

•Risk factors for immunosuppression

•Symptoms suggesting frontal or sphenoid sinusitis

•Presence of risk factors for antibiotic resistance– Previous antibiotic < 3 months– Day care exposure– Failure of first-line antibiotic

•Initial therapy with a second-line antibiotic– Amoxicillin/ clavulanic acid 875 mg BID x 10-14 d– Moxifloxacin 400 mg QD x 10-14 d

Follow-upFollow-up

•Symptoms are expected to improve, but not to resolve completely within 72 hours of initiation of therapy

•As she is expected to have a complete recovery, follow up is only necessary if she has either– no improvement of symptoms after 72h, or– aggravation of symptoms

•If so,– assess for development of complications– initiate first- or second-line antibiotic depending on initial treatment

Case in Chronic RhinosinusitisCase in Chronic Rhinosinusitis

•46 year-old male

•9-month history of fluctuating symptoms– Nasal obstruction– Facial pain in a mask-like distribution– Occasional cough– Intermittent postnasal drip

•Symptoms fluctuate over time

•3-times yearly become sufficiently severe for a diagnosis of acute sinusitis, and an antibiotic administered

•Medical history is otherwise significant only for penicillin allergy

•Physical examination is noncontributory

Case in CRS with Nasal PolyposisCase in CRS with Nasal Polyposis

•45-year-old male patient

•Consults for nasal obstruction that has been increasing over the past 18 months

•Treated in the past for sinusitis

•Currently pain free, but has intermittent yellowish anterior nasal discharge present

•Review of symptoms– No shortness of breath or episodes of wheezing– Has received a salbutanol inhaler for a lingering cough

•Admits to be anosmic

•Nasal examination: Pale grayish masses present in the middle meatus bilaterally

CT of the Sinus: Pan SinusitisCT of the Sinus: Pan Sinusitis

Questions?Questions?

Additional Resources

Sinusitis in General

Additional Resources

Sinusitis in General

Estimated Number of Cases of Rhinosinusitis Incidence of Rhinosinusitis in Core EU CountriesEstimated Number of Cases of Rhinosinusitis Incidence of Rhinosinusitis in Core EU Countries

Health Care Utilization & Work Time MissedHealth Care Utilization & Work Time Missed

Implications of Antibiotic ResistanceImplications of Antibiotic Resistance

•Increased risk for delayed or inappropriate therapy

•Increase in clinical failures

•Increased morbidity and mortality

•Estimates of unnecessary cost of resistance per year* (US) vary – $4 - 6 billion– $100 million - $60 billion

*Adjusted for inflation at 3% per year

Saravolatz LD, et al. Ann Intern Med. 1982;96:11-6; ASM. Antimicrob Agents Chemother. 1995;(Suppl.):1-23; Phelps CE, et al. Med Care.1989;27:194-203

Antimicrobial ResistanceAntimicrobial Resistance

•Do physicians contribute to the development of antibiotic resistance?

•Can we help reduce antibiotic resistance?

Percentage of Penicillin Non-susceptibleS. pneumoniae in Canada: 1988-2008Percentage of Penicillin Non-susceptibleS. pneumoniae in Canada: 1988-2008

Macrolide-resistant Pneumococci: Canadian Bacterial Surveillance Network, 1988-2008Macrolide-resistant Pneumococci: Canadian Bacterial Surveillance Network, 1988-2008

Rates of Penicillin and Amoxicillin Resistance Canada: 1988-2008Rates of Penicillin and Amoxicillin Resistance Canada: 1988-2008

Antimicrobial Use and Resistance by Country (European Surveillance of Antimicrobial Consumption Project)

Antimicrobial Use and Resistance by Country (European Surveillance of Antimicrobial Consumption Project)

Nasal Examination: TechniqueSymptom Duration: 8-12 weeksNasal Examination: TechniqueSymptom Duration: 8-12 weeks

Middle turbinateMiddle meatus

SeptumInferior turbinate

Nasal airwayInferior meatus

Floor of nose

For examination of the left side: index finger should rest on the tip of the nose.

For examination of the right side: index finger should rest on the cheek.

Visualizing the Middle Meatus: Key To Sinus DiseaseVisualizing the Middle Meatus: Key To Sinus Disease

Complications of Acute SinusitisComplications of Acute Sinusitis

•Orbital complications– Preseptal cellulitis– Abscess– Phlegmona– Blindness

•Cerebral complications– Meningitis– Extadural abscess– Intradural abscess

•Osteomyelitis

ComplicationsComplications

Nasal PolyposisNasal Polyposis

•Prevalence: 2 - 4%, increase > 40 years

•26 - 30% asthma

•Asthma: 7 - 15% nasal polyposis

•Nasal obstruction, reduced sense of smell

Larsen K. Allergy Asthma Proc. 1996;17:243-9. Johansson L et al. Ann Otol Rhinol Laryngol. 2003;112:625-9. Demoly et al. Allergy 2003:58:233-238.Fokkens et al. Rhinol Suppl, 2007(20): 1-136.

CT of the Sinus: NormalCT of the Sinus: Normal

Impact of INCS on CRS after ESSImpact of INCS on CRS after ESS

• Pre-op use of INCS associated with decreased rate of bacterial recovery at

ESS– Effect most pronounced for revision

cases, mainly for staphylococcal species– Corticosteroid may penetrate

sinus cavities better after ESS

• In individuals consulting for CRS persisting after surgical therapy, 61% had a

favourable response to irrigation with corticosteroid / saline solution

Desrosiers M, Hussain A, Frenkiel S, Kilty S, Marsan J, Witterick I, Wright E. Intranasal corticosteroid use is associated with lower rates of bacterial recovery in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2007;136:605-9.

Nader ME, Abou-Jaoude P, Cabaluna M, Desrosiers M. Using response to a standardized treatment to identify phenotypes for genetic studies of chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2010;39:69-75.

Prevalence of Erythromycin Resistance Among Pneumococci by Prior Macrolide UsePrevalence of Erythromycin Resistance Among Pneumococci by Prior Macrolide Use

sinusitis: what the primary care practitioner should do in 2011: a review of new canadian guidelines...

Documents

chronic rhinosinusitis

management of abrs slide

palpation slide

canada slide

evolution slide

bronchitis slide

bodily pain slide

therapeutic profile