Chronic Sinusitis

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Chronic Sinusitis

• Andre Tan, MD, FRCSC
• Department of Otolaryngology
• Queens University

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Definition

• 6-8 weeks of symptomatic infection
• irreversible mucosal changes

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Case Study

• Your patient is a 45 y.o. female with 3 episodes
  of acute sinusitis since last winter. Each time
  you treated with antibiotics with resolution of
  acute sx. However, she continues to c/o pressure
  sinus headache, nasal congestion, poor smell,
  and intermittent rhinorrhea.

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you diagnosis chronic sinusitis....

• History
• asthma
• nasal trauma
• Presenting sx
• Physical exam

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Common presenting sx

• nasal obstruction 94
• postnasal drainage 92
• facial pain headache 90
• rhinorrhea 61
• hyposmia / anosmia
• Matthews 1991

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Physical examination

• purulent rhinorrhea
• polyps
• dental abscess
• transillumination not helpful
• look for complications

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Pathophysiology

• obstruction of osteomeatal complex region
• impaired mucociliary clearance

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Anatomical variants

• deviated nasal septum
• concha bullosa
• ethmoid bulla
• other middle turbinate anomalies
• Agger nasi cells
• Haller cells

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Underlying diseases

• asthma
• cystic fibrosis
• ciliary dysmotility
• immuno-compromised
• chemotherapy
• transplant
• immuno-deficiency

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Is CT scan indicated?

• support your dx
• road map for your surgeon

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Objectives for treatment

• sterilization of sinus content
• resumption of normal sinus physiology
• prevention of complications

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Microbiology

• Anaerobes
• gm cocci, bacteroides, corynebacteria
• Frederick-52, Brook-80
• Staphylococcus aureus
• Streptococcus
• H. Influenzae
• M. catarrhalis

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Treatment options

• antibiotics
• sufficient duration (at least 3-4 weeks)
• selection???
• decongestants / mucoevacuants
• anti-inflammatory (steroids)

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Antibiotics

• none approved in Canada as indication for CS
• ciprofloxacin
• amoxicillin-clavulanate
• clarithromycin
• cefuroxime
• comparable -level 1 (Fombeur 1993)

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Antibiotics.......

• Ciprofloxacin 59 (89)
• Amoxicillin-clavulanate 51 (91)
• (Legent 1993)

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what should we use?

• beta-lactamase producers
• anaerobes
• amoxicillin-clavulanate
• Clarithromycin
• Clindamycin
• metronidazole

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Decongestants mucoevacuants

• maintain ostial patency
• level III evidence
• topical for lt 3 days
• naphazoline, phenylephrine oxymetazoline
• oral
• ephedrine, pseudoepephedrine.........
• beware of contra-indications

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Anti-inflammatory (steroids)

• generally not recommended
• theoretical advantage (IL-5R IL-13)
• use ONLY in inadequate response to abc,
  decongesant mucoevacuant
• to reduce tissue inflammation, edema
  hyper-reactivity (allergy)
• topical glucocorticoids (slow vs fast)

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when to refer?

• failure of treatment
• anatomical problems
• complications

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Sinus headache

• pain -- biopsychosocial model
• sinus headache/pain does NOT mean sinusitis
• pt relates to previous experience with sinusitis
• abc may have analgesic effect
• MUST have proper evaluation

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Chronic maxillary atelectasis

• Medial infundibular wall causes valvular
  occlusion of the ostium
• Subsequent decrease of sinus volume deformity
  of antral wall(s)
• Similar sx as chronic maxillary sinusitis
• May have cosmetic deformity
• More common than believed

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Chronic maxillary atelectasis

• Stage I
• Retraction of the membranous fontanel medial
  infundibular wall
• Stage II
• Inward bowing of one or more sinus wall
• Stage III
• Enophthalmus, hypoglobus, and/or mid-face
  deformity

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Chronic maxillary atelectasis

• Treatment
• Antibiotics for 2-4 weeks
• Decongestants (oral topical)
• Surgical - definitive