Otitis, Sinusitis and Bronchitis

Michael De Vito M.D.
Capital Region Otolaryngology Group
Albany, Troy, Clifton Park and Hudson
Affects 30 million individuals per year in the
90% of patients will see their primary care
Accounts for 11.6 million visits to primary care
physicians annually
Accounts for 9% of pediatric and 21% of adult
antibiotic prescriptions
Sinus Drainage Pathways
Pathogenesis of Sinusitis
Classification of Sinusitis
Sinusitis is defined as an inflammation of the mucous
membrane that lines the paranasal sinuses
It is classified chronologically as:
Recurrent Acute
Acute Exacerbation of Chronic
Acute Rhinosinusitis
• A New Infection That May Last Up To Four
• Can Be Subdivided Symptomatically Into
Recurrent Acute Rhinosinusitis
• Four or More Separate Episodes of
Acute Sinusitis That Occur Within One
Subacute Rhinosinusitis
• An Infection That Lasts Between Four
to Twelve Weeks
• Usually Represents a Transition From
Acute To Chronic Infection
Chronic Rhinosinusitis
• When Signs and Symptoms Last for
More Than Twelve Weeks
Diagnosis of Sinusitis
Viral Versus Bacterial Rhinosinusitis
• Viral Upper Respiratory Illnesses Occur:
3-8 per year in children
2-3 per year in adults
• Gwaltney: (1996,1994)
Found 90% of CT Scans Showed Evidence of
Sinus Involvement With Viral Rhinosinusitis
Viral Upper Respiratory Infection
Viral Versus Bacterial Rhinosinusitis
 Difficult to Differentiate
 Symptoms of Bacterial Sinusitis Worsen After Five
 Bacterial Infections Persist For At Least Ten Days
 Task Force On Rhinosinusitis Of The AAO-HNS
Diagnosis of Acute Sinusitis Depended On
The Presence of :
Two Major Diagnostic Factors
One Major Factor and Two Minor
Diagnostic Predictive Factors of
Acute Sinusitis Definitions
Radiographic Imaging
• Radiographic Imaging Should Not Be Used
In Patients That Meet The Diagnostic
Criteria of Acute Rhinosinusitis
• Exceptions Include:
A Potential Complication of Sinusitis
An Alternative Diagnosis is Suspected
Symptomatic Treatment
 Analgesics and Antipyretics for Pain and Fever
 Topical or Systemic Decongestants for Symptomatic Relief
Neither have been proven to prevent a URI
from becoming ABRS
 Topical Better Than Systemic for Congestion Relief
3 Day Maximum – Longer Rebound Concern
 Systemic Steroids Have Shown No Effectiveness
 Antihistamines Have No Studies As To Effectiveness
Symptomatic Treatment
• Topical Steroid Sprays Have Shown Some
Industry studies and included antibiotics
• Nasal Saline for Quality of Life Improvement
Decrease medication use for frequent ABRS
• Guaifenesin
Insufficient evidence
Most Prevalent Pathogens
in Adult Sinusitis
Staphylococcus aureus
Other (4%)
Moraxella catarrhalis
pneumoniae (20-43%)
Anaerobes (0-9%)
Streptococcus spp.
Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004.
AAOHNS. Otolaryngol Head Neck Surg. 2007.
Haemophilus influenzae
Empiric Treatment in Children
 Amoxocillin-clavulanate Rather Than
Increasing prevalence of H. influenza in
URIs in children
High prevalence of Beta-lactamase
producing pathogens in ABRS
H. influenza and Moraxella catarrhalis
IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis
Antibiotic Regimen in Children
Starting Empiric Antibiotic
• In Adults When Clinical Diagnosis Has Been
Established By The Guidelines
• Symptoms of rhinosinusits lasting more than 10
• Severe symptoms or high fever and purulent
nasal discharge or facial pain lasting 3-4
consecutive days at the onset of illness
• Worsening of symptoms with fever, headache or
increased nasal discharge at day 5-6 of a URI
that were improving.
IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis
Antibiotic Regimen for Adults
Treatment of Penicillin Allergic
• Skin Testing to Confirm of Exclude Immediate
• Adults:
Respiratory Floroquinolone
Macrolides or TMP/SMX
No Longer Recommended because of
increased resistance of S. pneumonia and
H. influenza
Children with Penicillin Allergy
• Children with Type 1 Hypersensitivity:
FDA approved for use only after Anthrax Exposure
2523 Children Studied in the Pediatric Levaquin
Study (Noel, 2007)
Well tolerated after 12 Months But
Musculoskeletal Events
1.9% vs. .79% at 2 months
2.9% vs.1.6% at 12 months
Probably Warranted with Type 1 sensitivity
Children with Non-Type 1
• Third Generation Oral Cephalosporin:
Cefixime, Cefpodoxime
• In Combination With Clindamycin
Duration of Therapy
 5-7 Days Seems Appropriate
Most patients studied by sinus puncture had
symptomatic improvement and bacteriological
eradication within 72 hours of initiation of
Treatment beyond 10 days for acute ,
uncomplicated patients seems excessive
Children Should Be Treated for 10-14 Days
Studies still lacking to recommend less
Nonresponsive Patients
• Patients Who Clinically Worsen After 72 Hours or
Fail to Improve After 3-5 Days of Empiric Therapy:
Resistant Pathogens
Noninfectious Etiology
Structural Abnormalities
• CT of MRI
Noninfectious causes of suppurative
• Sinus or Meatal Cultures
• Careful Clinical Assessment
Sinus Cultures
 Direct Sinus Aspiration :
Most Accurate but Invasive , Not Well Tolerated
 Middle Meatal Cultures:
Benninger (2006)
81% sensitivity, 91% specificity,
83% predictive value
 Nasopharyngeal Swabs:
Allergy Evaluation
 Chronic Sinusitis And Allergy:
40-80% of Adults
25-31% Young Adults
 Should Be Considered In:
Chronic Rhinosinusitis
Recurrent Acute Rhinosinusitis
 Skin Testing As The Preferred Testing Method
 Patients with Chronic Rhinosinusits or Recurrent
Acute Sinusitis
 Failure of Aggressive Medical Therapy or Persistent
Purulent Infection
 Most Common Disorders:
Selective IgA Deficiency
IgG Subclass Deficiency is Unclear
HIV Patients ( 30-68%)
Fungal Sinusitis
 Mycetoma Fungal Sinusitis
“Fungus Ball” Usually in the Maxillary Sinus
Treatment is Surgical Removal of the Lining
 Allergic Fungal Sinusitis
An Allergic Reaction to Environmental Fungi
Immunocompetent Host
Thick Fungi and Mucin Accumulate
Surgical Removal of the Allergen(Fungi)
Fungal Sinusitis
 Chronic Indolent Sinusitis
Generally outside the U.S. (Sudan, India)
No Immune Deficiency
Progresses from Month to Years
Characterized by a Granulomatous Inflammatory
Fulminant Fungal Sinusitis
 Immunocompromised Patients
Immunodefeciency Disorders (Diabetes)
Immunosuppressive Agents
Can Result in Progressive Destruction of the
Sinuses with Resulting Invasion of the Eye or
Cranial Cavity
Mucormycosis a common fungi
Sinus Headache
Clinical History:
Primary Complaint is Headache Without
Significant Nasal Symptoms – Migraine
Headache Embedded In Other Bothersome
Nasal Symptoms Evaluation of Nasal and
Sinus Cavities Warranted
Headache is a Minimal or Inconspicuous
Complaint Rhinosinustis May Be Likely
Sinus Headache
 Physical Exam:
Nasal Exam Findings Which May Suggest
Secondary Pathology:
Inflammatory Changes (Allergy)
Anatomic Abnormalities
Purulent Nasal Discharge
 Testing:
Imaging Can Be Useful – False Positive Results
Sinus Headaches
 Sinus Disease As A Cause of Headache Has Been
Ingrained Into The American Public
Little Evidence to Support This
 Migraine Can Present With Facial Pain, Nasal
Congestion and Rhinorrhea.
 In Clinical Studies Nearly 90% With Self-Diagnosed or
Physician Diagnosed Sinus Headache Met The Criteria
for IHS Migraine-Type Headaches.
 Most Responded To Triptan Interventions
Sinus Headaches
Specialist Referral
 90% of Patients Can Be Treated and Cured of Sinusitis
With Medical Therapy
 Surgical Treatment:
For the Treatment of Anatomic Obstruction
(Polyps,Septal Deviations)
Recurrent Acute Infections
CRS Non-Responsive To Medial Therapy
Surgical Treatment
 Functions Endoscopic Sinus Surgery (FESS):
All done through the nose
Removal of Abnormal and Obstructive Tissue To
Restore the Normal Drainage Pathways of the
Results in Removal of Less Normal Tissue
Can Be Done as an Outpatient
Surgical Treatment
• Image Guided
Three Dimensional View
of the Surgical Field
For Severe Cases or
Patients Who Have Had
Prior Surgery
Requires a Planning CT

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