Epistaxis

Epistaxis:

Epistaxis is defined as bleeding from the nose due to any cause.

can be,local or systemic.

Through :anterior nares and posterior nares

Origin of blood from:

• Nose
• Nasopharynx
• PNS
• Antrior cranial fossa

VASCULAR ANATOMY:

Nose is supplied by both external & internal carotid systems.

External carotid system comprises of:

• Sphenopalatine br of Maxillary A
• Gr.Palatine br of Maxillary A
• Superior labial br of Facial A
• Internal carotid system (Ophthalmic A) comprises of:
• Ant ethmoidal Artery
• Post ethmoidal Artery

LITTLE's AREA

Situated in the ant inf part of nasal septum

Kiesselbach’s plexus comprised by:

•Ant ethmoidal

• Septal br of Sup labial

• Gr.Palatine

•Septal br of SPA

LITTLE's Area

Exposed to drying inspiratory air currents and digital trauma

Commonest site of epistaxis in children and young adults

Leads to arterial bleeding.

RETROCOLUMELLAR VEIN:

A vein running down just behind the columella crossing the floor and joining the venous plexus the lateral wall of nose .May bleed in young people

WOODRUFF's PLEXUS:

Venous plexus on the lateral wall of the inf. meatus posteriorly.Also called naso-nasopharyngeal plexus .Site of epistaxis in elderly

SPHENOPALATINE ARTERY:-

Artery of epistaxis .Terminal br of int maxillary Artery.Enters nose by traversing the sphenopalatine foramen.

SITE OF EPISTAXIS:

Little’s area ,Woodruff’s area ,Above middle turbinate (ant & post eth.A).Below middle turbinate (br of SPA),Diffuse bleeding,Nasopharynx,Roof of nasal cavity ,Post. Part of nasal septum (Brown’s area) .

PATHOPHYSIOLOGY:

Various factors are involved.Vessel wall damage by trauma ,Sudden rise of pressure(violent exp effort) in a weak vessel wall rupture,Inherent weakness of capillary wall,Infection,inflammation,fragility of capillary wall,bleeding,Vitamin deficiencies (K,C) cause weakness of capillary wall ,clotting factor deficiency

Impaired coagulation eg:epistaxis as in coag disorders, aspirin

AETILOGY:

Age: Children: nosepicking, FB, adenoids, diphtheria , adolescent: JNA, trauma, rhinosinusitis ,adults: infection, injuries,lderly: HT, neoplasm, sex: no sex prediliction.

It can be due to Local,systemic and idiopathic factors.

LOCAL:

• Most common
• Can be
• Congenital - multiple telangiectasiasis(Osler Rendu Weber syndrome)
• Traumatic
• Foreign body
• Inflammation ,neoplasm,miscellaneous..

LOCAL TRAUMATIC:-Digital trauma

• Nasal #
• # ant cranial fossa
• Surgical trauma
• Chemical trauma…eg..arsenic
• Traumatic septal perforation
• Forceful blowing of nose and sneezing
• local foriegn body:-
• Maggots
• Rhinolith
• Neglected FB

LOCAL INFLAMMATION:Acute non specific rhinosinusitis

• Acute specific—nasal diphtheria
• Chronic non specific
• Atrophic rhinitis
• Rhinitis sicca
• Rhinitis caseosa
• Chronic rhinitis

Chronic specific :

• Rhinosporidosis
• TB, Lupus
• Syphilis
• Leprosy
• Rhinoscleroma

LOCAL NEOPLASMS:-

Benign growth, bleeding polyps of septum, angiofibroma, inverted papilloma

Malignant growths of the nose, PNS and nasopharynx

LOCAL-miscellaneous:-

• Vicarious menstruation
• Barotrauma
• Deviated nasal septum

SYSTEMIC:-

• Congenital- hemophilia and other disorders of coagulation
• Infective

• Disorders of blood and blood vessels
• Systemic diseases
• Drugs
• Mediastinal compression
• miscellaneous

SYSTEMIC-Infective:-

• Acute exanthematous fevers—measles, varicella, influenza
• Malaria
• Typhoid
• Kala-azar
• Pertussis
• Rheumatic fever
• Dengue fever
• Infectious mononucleosis

Blood and blood vessels:-

• Purpuras
• Leukemias
• Haemophilias
• Aplastic & pernicious anaemias
• Vit K def
• DIC

SYSTEMC DISEASES:-

• Hypertension
• Atherosclerosis
• Mitral stenosis
• Cirrhosis
• Chronic nephritis

DrUGS:-

• Anticoagulants
• Aspirin
• Phenytoin

SYSTEMIC:-

• Mediastinal compression by tumours of the lower neck and mediastinal growths

Miscellaneous:

• Prolonged exertion
• Pregnancy
• Puberty

Management:-

• Surgical emergency
• Treatment consists of
• Assess gen condition of patient and resuscitate if necessary
• Local measures to stop haemorrhage
• Treatment of the specific cause of bleeding

General measures:-

• Record vital signs
• Hb, PCV
• history-amount of bleeding, ppt cause, medical illness, drugs, family history
• Fluid replacement
• Blood transfusion
• Oxygen masks
• Bleeding profile, X-rays, CT scans if required

Management:-

• Control of hypertension
• Correction of coagulopathies/ thrombocyto penia
• FFP or whole blood/reversal of anticoagulant/platelets
• Topical decongestants/vasocontrictors
• Cautery (AgNo3 vs. TCA vs. Bipolar)
• Nasal packing (effective 80-90% of time)
• Greater palatine foramen block.
• Humidity/emolients
• Discontinue offending meds
• Nasal saline sprays
• Avoidance of nose picking/blowing
• Sneeze with mouth open
• Avoid straining/bedrest .

LOCAL MEASURES:-

• Temporary pressure over alae—pinch nose with pt upright
• Ice cubes over nose—vasoconstriction
• Trotters method: NOT DONE NOW
• Pt sit on a chair leaning forward with open mouth—bleed till hypotensive. Risk of coronary thrombosis .

CAUTERIZATION:-

• Nasal endoscopy after local spray to locate bleeding point.
• Cauterization of the bleeding point
• Chemical cautery :
• 50% trichloroacetic acid
• 10% silver nitrate
• Electric cautery
• Cryo cautery

NASAL PACKS:-

• Anterior nasal packs
• Traditional
• Recent modifications
• Posterior nasal packs
• Traditional
• Recent modifications
• Ant/Post nasal packing .

Complications of nasal packing:-

• Early:pain,vasovagal attack,injury to soft palate,columella,nares,mucosa,choana.

Intermediate :

• Hypoxia & hypoventilation
• Sleep
• Apnoea
• Arrythmias and cardiac arrest
• ET dysfunction

Late :

• Secondary haemorrhage
• Septal necrosis and perforation
• Toxic shock syndrome
• Synechiae
• Atrophic rhinitis

Surgical treatment:-

• Last resort in epistaxis control
• ECA ligation as 90% mucosa is supplied by it
• Arteries that can be ligated are:
• Internal maxillary A: transantral/ transoral approach
• ECA: cervical incision
• Sphenopalatine A: transantral/ endoscopic
• Ant and Post ethmoid A: Lynch incision

EMBOLIZATION:-

For severe post epistaxis—IMA embolized

Using gelfoam, oil, balloon, poly vinyl alcohol particle

Side effect: CVA

Nasal balloon:-

• For posterior epistaxis
• Foley’s catheter is used
  
• Catheter with 2 balloons--- one in nasopharynx and other in the nasal

Allergic rhinitis

Definition
- an inflammation of the mucous membrane lining the nose (usually associated with nasal discharge sneezing, congestion and irritation in the nose, eyes, throat and ears.)


Classification of rhinitis
A. Allergic
Seasonal
Perennial
Occupational

B. Non allergic
Infection
Intrinsic rhinitis
Others.

Allergic Rhinitis-definition:-
Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose

ATOPY
Tendency to develop an exagerrated antibody response( IgE) to common aero allergens.
Allergy is its clinical expression.
Genetically inherited.
Elevated IgE OR Exagerrated skin prick test

SEASONAL RHINITIS
Allergy to grass pollen,fungal spores
Nasal mucosa may be primed .
A pollen count of more than50/l provokes usually.
More in the evening when pollens settle down.

Evening time is when the pollenssettle down on the ground.

PERENNIAL ALLERGIC RHINITIS
Caused by the digestive enzymes of house dust mite (Dermatophagoides pteronysinnus and D.farinae.
In pillows carpet bedclothes ,curtains ,soft furnishings.
Also cat salivary protien.

Dust Mites (Der p, Der f)
Eight legged arachnids (related to spiders, chiggers and ticks)
Thrive in warm moist micro-environments (inside pillows, cushions, mattresses)
Feed on human and animal dander (dead skin flakes)
Focus on the bedroom
Pillow and mattress covers
Wash bedding in hot water
Damp dust
Cost effective tips
(cheese cloth)

OCCUPATIONAL ALLERGENS
Flour (bakers,grain workers)
Lab animals
Washing powders
Wood dust
Latex-important in surgeons,nurses and other health workers.
Furry and Feathered Friends (Can d1, Fel d1, Mus m)
Dander: proteins in dead skin, urine and saliva
Cats (most common)
Dogs
Birds
Rodents

FOOD AND DRUG INDUCEDRHINITIS
Ig E mediated
Symptoms in mouth tongue and digestive tract.
Sensitivity to preservatives like sulphites,benzoates and tartrazine.
Saint’s or Samter’s triad-Aspirin induced rhinitis,nasal polyposis and late onset asthma.

Allergic rhinits-Aspirin triad:-
Nasal Polyposis
Allergic Sinusitis
Asthma

Natural history of allergic rhinitis:-
onset is common in childhood,adolescence and early adulthood.Symptoms often wane in older adults,but may develop or persist at any age.No apparent gender selectivity orpredisposition for developing allergic rhinitis.May contribute to other conditions such as sleep disorders,fatigue,learning problems.

MEDIATORS OF ALLERGY
From granules and cellmembrane of basophils and mast cells.
Histamine-itch,sneezing and mucous secretion
LeukotrieneC4-Mucous secretion
LKB4 and PAF-Eosinophil,Neutrophil chemoattractant

How are the symptoms caused?
Irritation of freenerve endings---- Itching and sneezing
Increasedmucus production ------ Rhinorrhoea
Vasodilation -------- Congestion
Increasedvascular permeability---- Oedema


Diagnosis of AR
History
Physical / Nasal Examination
Laboratory investigations
-Routine blood;look for eosinophilia
- Skin Prick Test
- RAST
-Nasal lavage for eosinophils

CLINICAL MANIFESTATIONS:-
Repetitive sneezing,watery rhinorrhea,nasal pruritus,nasal congestion
others:-eye symptoms,ear symp,postnasal drainage.

Physical examination:-
nAllergic shiner
nDennie Morgan line(prominent creases below inferior eyelid)
nAllergic crease
nAllergic salute
nNasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic
nExclude structural problems (polyps, deflected nasal septum)
Others:
nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability

Allergic testing-Prick test:-
Patients have to be off of all antihistamines for 4 days. Off of non-sedative antihistamines for up to 6 weeks.
Cannot be on Beta Blockers.

Skin prick testing
It is usually carried out on the inner forearm,but if the patient has bad eczemaon the test can be performed on the back
Ideally the allergens to be selected should be in accordance with the patient’s history
As few as 3 or 4 or up to about 25 allergens can be tested
The arm is coded with a marker pen for the allergens to be tested
A drop of the allergen (extract) solution is placed by each code.

Radio allergosorbent test:-the blood measures of allergy antibody or IgE,produced when your blood is mixed with a series of allegens in a laboratory.

Management of AR:-
Allergen Avoidance
Pharmacotherapy
Immunotherapy

Animal Control Measures:-
The ideal solution:
Remove pets from house
If not possible:
Keep pet out of bedroom
Use HEPA air filtering system
Remove carpet and other reservoirs for allergens in the bedroom
Encasing on mattress, box springs, and pillow
Wash pet weekly.

Outdoor Triggers:-
Pollens: particles released from trees, weeds and grasses
Highest levels at midday (10-2pm)
Use air conditioning, not fans
Visit an air-conditioned mall or movie theater
Not many options (avoidance)

Pharmacotherapy:-
Medications used to treat allergic rhinits:
Antihistamines
Decongestants
AH-D combinations
Corticosteroids
Mast Cell stabilizers
Anticholinergics
Antileukotrienes

Anti-Histamines:-
Act by preventing histamine from binding to the H1-receptors
Primarily helpful in controlling Sneezing, itching & rhinorrhoea; ineffective in releiving nasal blockage
1st generation anti-histamines
- chlorpheniramine
- diphenylhydramine
2nd generation anti-histamines
- cetrizine
- azelastine
- fexofenadine
- loratadine

Intranasal corticosteroid therapy:-
Potent topical activity
Administration of low doses directly at site of action
Considerable efficacy at low doses
High topical: systemic activity ratios
Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity
Markedly greater inhibition of EAR than with oral steroids

Immunotherapy:-
Allergy shots (immunotherapy) for allergic rhinitis Treatment Overview
When you get allergy shots (immunotherapy), your allergist or doctor injects small doses of substances that you are allergic to (allergens) under your skin. This helps your body "get used to" the allergen, which can result in fewer or less severe symptoms of allergic rhinitis.
Your allergist will use an extract of grass, weed, or tree pollen; dust mites; molds; or animal dander for allergy shots. You must first have skin testing to find out which allergen you are allergic to.

The "Ideal" Drug For Allergic Rhinitis Should Have The Following Features:
Inhibit both early and late phases
Be an H1 blocker
Counter effects of other mediators
Fast-acting, to control the early phase
Dosing-od or bd for compliance
No side effects
Manage all symptoms
Intranasal administration

The "Ideal" Drugs Are……
"Corticosteroids are undoubtedly the pharmacotherapeutic agents with the broadest application for the treatment of many types of rhinitis"

Vasomotor Rhinitis

VASAOMOTOR RHINITIS is a condition of unknown etiology characterized by a combination of nasal obstruction, watery rhinorrhoea and sneezing.


Predominance of parasympathetic activity leads to SYMPTOMS.



Aetiology:-
Predisposing factors are
Heredity
Infection
Psychological and emotional factors – ‘stress’
Endocrine – puberty, pregnancy, myxoedema
Drugs – beta blockers, methyl dopa, aspirin
Local applications – rhinitis medicamentosa .

precipitating factors are:-
Atmospheric conditions – changes in humidity, temperature
Fumes, dust, alcohol
Reflex .

PATHOLOGY:-
Mucosa is generally hyperemic and hypertrophic
Polypi can be seen.There may be inferior turbinate hypertrophy

Age:-It affects peples of any age.

Clinical features are:-
Similar to allergic rhinitis
Drippers
Blockers
Sneezing
Rhinorrhoea
Nasal obstruction
Post nasal drip
‘Nasal tip dew drops’ in elderly patients .

Differential Diagnosis:-
Allergic rhinitis
Infection
FB, adenoid etc in children

TREATMENT:-
Avoidance eg. Drugs
Antihistamines
Topical steroids
Cryo surgery
SMD
Polypectomy
Vidian neurectomy
Psychological adjustments, sedatives and tranquilizers

Antrochoanal polyp

Antrochoanal polyp(synonym-Killian's polyp)

Arise from mucosa of maxillary antrum
Prolapse thru acc ostium into nasal cavity
Ostium directed backwards---grow towarda choana
Mostly u/l
Younger males

Aetiology:-
Exact– not known
Infection od sinuses with concurrent allergy
Proetz __may arise due to maldeveloped, large max sinus ostia

Site of origin:-
Arise from lateral wall or floor of max antrum
If large, obstructs entire nasopharynx---nasal onstruction b/l.

Has 3 parts:
Antral
Nasal and
choanal
The neck is that constricted part between antral and nasal part---site where it exits from the ostium

SYMPTOMS:-
Nasal obstruction:
Usually u/l, b/l if fills nasopharynx
Nasal discharge:
Mucoid –mucopurulent
Hyposmia and anosmia
changes of voice– hyponasality with loss of nasal resonance (rhinolalia clausa).
Fullness of ears and decreased hearing—
Due to obstruction of eust. tube,

Signs:-
May protrude through the nostril or hang down behind soft palate
A/R: normal in early stages
Later stages, polyp seen in post part of MM
Post rhinoscopy—smooth, greyish white,translucent, oedematous, spherical mass in the choana and nasopharynx on the affected side
Soft palate may be pushed forwards

Investigations:-
X-ray nose and PNS—haziness of the affected sinus
X-ray lat view of nasopharynx—mass in nasopharynx
A cresentic air column between the roof of nasopx and polyp is characteristic and differentiates it from angiofibroma, adenoma or mass from the roof of nasopharynx

Treatment:-
Surgical
Intranasal AVULSION polypectomy
FESS—endoscopic removal of polypalong with widening of the natural ostium
Caldwell-Luc operation—prior to FESS’opening of max antrum thru sublabial approach thru canine fossa and removal of the polyp and diseased mucosa
Not done in children—as dentition is incomplete

Differential diagnoss of nasal polyp:-
Hypertrophic inf turbinate
JNA
Meningoencephalocoele
Rhinosporidiosis
Inverted papilloma
Granulomatous lesions like TB
Malignant tumours of nose


Why polyp goes backward?
–Accesory ostium is posteriorly situated
–Ostium directed backwards
–Obliquity of posterior part of IT-polyp slides
–Negative pr. created during swallowing, etc.
Caldwell-Luc operation:-Its a surgical procedure for its treatment.



.

ACUTE AND CHRONIC SINUSITIS

                                       ACUTE AND CHRONIC SINUSITIS

Definition:-

Inflammation of the sinus mucosa

• Usually associated with rhinitis .Rhinosiusitis may be better term because:
• Allergic or nonallergic rhinitis nearly always precedes sinusitis
• Sinusitis without rhinitis is rare
• Nasal discharge and congestion are prominent symptoms of sinusitis
• Nasal mucosa and sinus mucosa are similar and are contiguous

Normal sinus:

Sinus health depends on:

Mucous secretion of normal viscosity, volume, and composition,

normal mucociliary flow to prevent mucous stasis and subsequent infection;

and open sinus ostia to allow adequate drainage and aeration.

Developement of sinuses:

• Maxillary and ethmoid sinuses present at birth
• Frontal sinus developed by age 5 or 6
• Sphenoid sinus last to develop, 8-10

Physiologic imprtance of sinuses:-

• Provide mucus to upper airways
• Lubrication
• Vehicle for trapping viruses, bacteria, foreign material for removal
• Give characteristics to voice
• Lessen skull weight
• Involved with olfaction

Sinusitis:-Infectious or noninfectious inflammation of 1 or more sinuses.

4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells

• Frontal
• Maxillary
• Ethmoid
• Sphenoid

Normal Water’s and Towne’ s Views of the sinuses:-

 

 

 

 

 

 

 

 

 

 

   
Lateral View Showing Normal Sphenoid Sinus :-

OSTEOMEATAL COMPLEX:-

• Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain
• Posterior ethmoids drain into the upper meatus
• Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

VIRAL RHINOSINUSITIS:-

• Most upper respiratory infections are viral
• Short lived, last less than 10 days
• Sinus mucosa as well as nasal mucosa is involved
• Most will clear without antibiotics
• Treatment: decongestants, nasal lavage, rest, fluids

Classification of bacterial sinusitis:-

• Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)
• Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days)
• Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)
• Some guidelines add treatment failure + a positive imaging study

DIFFERENTIATING SINUSITIS FROM RHINITIS

Sinusitis :-

• Nasal congestion
• Purulent rhinorrhea
• Postnasal drip
• Headache
• Facial pain
• Anosmia
• Cough, fever

Rhinitis :-

• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

Road to bacterial sinus infections:-

• Rhinitis
• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

  X-Ray Image of Sinuses with Maxillary Sinusitis:-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  Pathogenesis of nasal obstruction:-

• Viral upper respiratory infections
• Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
• Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
• Deviated septum, concha bullosa, polyps

Allergic stimuli causing Rhinosinusitis:-

• Pollens
• Tree, grass, weeds
• House dust mite
• Animal danders
• Cat, dog, mice, gerbil, other animals with fur
• Molds
• Allergic foods and beverages

Non-allergic stimuli causing rhinosinusitis:-

• Tobacco smoke
• Perfumes
• Cleaning solutions
• Burning candles
• Cosmetics
• Car exhaust, diesel fumes
• Hair spray
• Cold air
• Dry air
• •Changes in barometric pressure
• •Auto exhaust
• •Gas, diesel fuel
• •Nonallergic foods
• •Nonallergic beverages

Causes of ciliary dysfunction:-

•Immotile cilia syndrome

•Prolonged exposure to cigarette smoke

•Common cold viruses causing URI

•Increased viscosity of mucus

•Medications

–First generation antihistamines (non sedating do not affect)

–Anticholinergics

–Aspirin

–Anesthetic agents

–Benzodiazepines

Diseases slowing ciliary function:-

•Allergic and nonallergic rhinitis

•Rhinosinusitis

•Aging rhinitis

•Cystic fibrosis

•Any disease causing obstruction, crusting of the mucosa

Causes of mechanical obstruction:-

•Deviated nasal septum

•Concha bullosa

•Foreign body

•Nasal polyps

•Congenital atresia

•Lymphoid hyperplasia

•Nasal structural changes found in Downs syndrome

Vasculitides,autoimmune and granulomatous diseases:-

•Churg-Strauss vasculitis

•Systemic lupus erythematosis

•Sjogren’s syndrome

•Sarcoidosis

•Wegener granulomatosis

Other predisposing conditions:-

•Physical trauma

•Scuba diving

•Foreign body

•Cleft palate

•Dental disorders

•Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis

Acute Bacterial sinusitis:-

•Usually begins with viral upper respiratory illness

•Symptoms initially improve, but then …

•Symptoms become persistent or severe

•Persistent… 10-14 days but fewer than 4 weeks

•Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill

•Disease clears with appropriate medical treatment.

PHYSICAL FINDINGS:-

•Mucopurulent nasal discharge

•Swelling of nasal mucosa

•Mild erythema

•Facial pain (unusual in children)

•Periorbital swelling

Maxillary sinusitis:-

•Etiology-viral,bacterial rhinitis,dentogenic,trauma.

•Symptoms-facial pain,toothache,facial heaviness,facial redness.

•Signs-tenderness over canine fossa,mucopus in the middle meatus

FRONTAL SINUSITIS:-

•Etiology-viral and bacterial rhinitis,trauma,adjacent sinus infections

•Symptoms-heaviness of head in creasing on stooping down,office headache-peak during midday.

•Signs-tenderness on the floor of the frontal sinus,mucopus on the anterior middle meatus.

ETHLOID SINUSITIS:-

•Associated with infection of the other sinuses.

•Pain inbetween the eyes,eyelid edema.

SPHENOID SINUSITIS:-

•Isolated involvement is rare

•Headache in the occiput or the vertex.

•Look for any predisposing causes in the nasopharynx

Treatment of acute sinusitis:-

•Antihistamines recommended if allergy present

–Oral or topical

•Decongestants

–Oral or topical

•Antibiotic when indicated (bacteria)

•Nasal irrigation

•Guaifenesin 200-400 mg q4-6 hrs

•Hydration

DECONGESTANTS:-

•Topical nasal sprays (limit use to 3-7 days)

–Phenylephrine

–Oxymetazoline

–Naphthazoline

–Tetrahydrozoline

–Zylometazoline

•Topical nasal spray (unlimited daily use)

–Ipatropium

•Oral

–Pseudoephedrine 30-60 mg

–Phenylephrine 2-4 times/day

Antibiotics for Acute Bacterial Sinusitis:-

•Amoxicillin 500 mg tid for 10-14 days

–First line choice in most areas

–Local differences in antibiotic resistance occur

•Where beta-lactanase resistance is an issue

– Amoxicillin/clavulanate

–Cefuroxime

–Cefpodoxime

–Cefprozil

Additional Antibiotics for Acute Bacterial Sinusitis:-

•Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)

•If penicillin-allergic clarithromycin or azithromycin

•Erythromycin does not provide adequate coverage

•Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

Nasal Irrigation:-

•Washes away irritants

•Moistens the dry nose

•Waterpik with nasal irrigator

•Ceramic irrigators

•Enema bucket with normal saline and sodium.

When Medical Therapy for Acute Bacterial Sinusitis Fails…:-

•Assess for chronic causes

–Identify allergic and nonallergic triggers

•Allergy testing, nasal smears for eosinophilia

–Consider other medical conditions associated with sinusitis

–Rhinolaryngoscopy

–Imaging studies

Sinus x-rays

CT scanning (limited, coronal views)

Sinus Transillumination:-

•Helpful in older children and adults

•Normal transillumination decreases chance of pus in the sinus

•No light reflex suggests mucopurulent material or thickening of nasal mucosa

•Inexpensive screening tool

 

Bacteria Involved in Acute Bacterial Sinusitis:-

•Streptococcus pneumoniae 30%

•Haemophilus influenza 20%

•Moraxella catarrhalis 20%

•Sterile 30%

Chronic Sinusitis:-

•Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children

•Eosinophilic inflammation or chronic infection

•Associated with positive CT scans

•Poor (if any) response to antibiotics

Sx of Chronic Sinusitis:-

•Nasal discharge

•Nasal congestion

•Headache

•Facial pain or pressure

•Olfactory disturbance

•Fever and halitosis

•Cough (worse when lying down)

Conditions Causing Chronic Sinusitis:-

•Allergic and nonallergic rhinitis

•Uncorrected anatomic conditions

•Ciliary dyskinesia

•Cystic fibrosis

•Tumors

•Immunodeficiency disorders

–IgA, IgM

•Granulomatous diseases

Evaluation of Chronic Sinusitis:-

•CT or MRI scanning

–Anatomic defects, tumors, fungi

•Allergy testing

–Inhalants, fungi, foods

•Sinus aspiration for cultures

–Bacterial

-Fungal

•Immunoglobulins

Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown:-

•Streptococcus pneumoniae

•Haemophilus influenza

•Moraxella catarrhalis

•Staph aureus

•Coagulase negative staphylococcus

•Anerobic bacteria

Conservative treatment of Chronic Sinusitis:-

•Nasal steroid spray

•Guafenesin

•Decongestants

•Steam inhalation

•Nasal irrigation

•Antibiotics with exacerbations

Surgical treatment:-

•Maxillary sinusitis-Antral puncture,Intranasal antrostomy,Caldwell Luc operation.

•Frontal-Trephination,Howarths operation,Osteoplastic flap operation

•Ethmoids-Intranasal and External ethmoidectomy

•Sphenoid-Sphenoidotomy

•Functional Endoscopic sinus surgery

Recommendation 2b:-

•CT scans of the paranasal sinuses should be reserved for:

–Patients in whom surgery is being considered as a management strategy

–Patients who do not respond to medical regimes which include adequate antibiotic use

–Assisting in diagnosis of anatomical changes interfering with airflow or drainage

Recommendations for CT Scans:-

•Patients presenting with complications of sinusitis

–Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema

•Patients with sinus symptoms accompanied by severe, boring, mid-head pain

–Rule out sphenoid sinusitis

Summary:-

•Acute and chronic sinusitis is one of the most common diseases treated in family practice

•It is important to treat sinusitis aggressively to prevent chronic symptoms or development of serious complications

•The underlying causes of chronic sinus disease should be sought out and corrected