5 rhinitis

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Acute Rhinitis Acute Rhinitis Chronic Rhinitis Chronic Rhinitis Acute Acute Rhinosinusitis Rhinosinusitis Chronic Chronic Rhinosinusitis Rhinosinusitis Nasal endoscope Surge Nasal endoscope Surge ry ry Otorhinolaryngolo Otorhinolaryngolo gy gy The Third Affiliated Hospital of Sun Yat-sen University The Third Affiliated Hospital of Sun Yat-sen University Zhang Gehua [email protected] Zhang Gehua [email protected]

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Transcript of 5 rhinitis

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Acute RhinitisAcute RhinitisChronic RhinitisChronic Rhinitis

Acute Acute RhinosinusitisRhinosinusitisChronic Chronic RhinosinusitisRhinosinusitis

Nasal endoscope SurgerNasal endoscope Surgeryy

OtorhinolaryngologOtorhinolaryngologyy

The Third Affiliated Hospital of Sun Yat-sen University The Third Affiliated Hospital of Sun Yat-sen University Zhang Gehua [email protected] Gehua [email protected]

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Introduction 3 min Anatomy 5min Acute rhinitis 5min Chronic Rhinitis 5min Actue Rhinosinusitis 20 min Chronic Rhinosinusitis 20 min Nasal endoscope surgery 15 min Conclusion & Questions 10 min

ScheduleSchedule

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Acute Acute RhinitisRhinitis

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DefinitionDefinition

Acute Rhinitis: An acute condition which affects

the nasal mucous caused by inflammation.

Characterized------ runny nose and stuffiness,

usually caused by the common cold

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SymptomsSymptoms

latent period: 1~3days Course: 7 ~ 10days Sore throat Discomfort in the nose Sneezing, Runny nose (watery & clear ---thicker &

yellow -green) Mild fever Mild cough Others: Headaches, Decrease in ability to smell,

Nasal obstruction

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ComplicationsComplications

Sinuses (maxillary sinusitis, frontal sinusitis and

some other kinds of sinusitis)

Middle ear (otitis)

Eye mucosa (conjunctivitis)

Other respiratory organs (pharyngitis,

laryngitis, tracheitis, bronchitis, pneumonia)

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TreatmentTreatment

Decongestants: which help open clogged nasal passages (<7days)

Antihistamines: which help dry a runny nose Cough syrups: which may make coughing easier by

thinning secretions or suppressing cough Antibiotics:

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Chronic Chronic RhinitisRhinitis

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Chronic rhinitis is usually an extension of acute rhinitis

caused by inflammation or an infection.

------It also may occur with diseases such as syphilis,

tuberculosis, rhinoscleroma , rhinosporidiosis,

leishmaniasis, blastomycosis, histoplasmosis, and

leprosy.

DefinitionDefinitionDefinitionDefinition

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nasal obstruction

pus-filled discharge from the nose

frequent bleeding

SymptomsSymptomsSymptomsSymptoms

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Medication: Decongestants Chinese medicine nasal spray (nasonex, flonex)

Surgery: partial inferior turbinectomy inferior turbinate ablation…....

TreatmentTreatmentTreatmentTreatment

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RhinosinusitisRhinosinusitis

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AnatomyAnatomy

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AnatomyAnatomy

Frontal sinus

eye

Maxillary sinus

Inferior turbinate

Middle turbinate

Uncinate process

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Sinus Drainage SchemaSinus Drainage Schema

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Anterior group: MaxillaryAnterior ethmoid Middle meatal Frontal

Posterior group :Sphemoid Sphenoethmiodal recess Olfacotory cleftPosterioe ethmoid Supper meatal

Sinus DrainageSinus Drainage

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Definitions of rhinosinusitisDefinitions of rhinosinusitis ------------based on the duration clinical signs and based on the duration clinical signs and symptomssymptoms Acute rhinosinusitis: <4 weeks Subacute rhinosinusitis : 4 to 12 weeks Chronic rhinosinusitis : >12 weeks Recurrent acute rhinosinusitis: ≥4 episodes/yr (each episode

lasting ≥7 to 10 days plus no intervening signs of CRS) Acute exacerbation of chronic rhinosinusitis :sudden worsening

of CRS, return to baseline after treatment

1996,American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS)

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DefinitionDefinition

Acute Rhinitisinusitis: Inflammatory and/or

infectious condition of 1 or more of the

paranasal sinus cavities.

Acute rhinosinusitis (ARS) implies that the

duration of the condition is less than 1 month.

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EpidemiologyEpidemiology

0.5 to 2% of cold result in ARS (acute rhinosinusitis) Up to 1 in 20 URI (upper respiratory tract infections) lead to ABRS

(acute bacterial rhinosinusitis)

One billion cases of acute viral rhinosinusitis can be anticipated annually

20 million cases of ABRS are expected annually

Approximately 2% of people with acute viral rhinosinusitis go on to develop ABRS

The diagnosis of ABRS accounted for 21% and 9% of all adult and pediatric antibiotic prescriptions, respectively

Affects 32 million US adults annually

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CostCost

Resulted in 11.7 million office visits as well as 1.2 million hospital outpatient unit visits

Generated direct annual costs in excess of $3.4 billion in that same year

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PathogenesisPathogenesis

Viral:Viral: Rhinovirus Influenza A and B

viruses Parainfluenza virus Respiratory symcytial

virus Adenovious….

Bacterial:Bacterial: Streptococcus pneumoniae

Haemophilus influenzae,

Moraxella catarrhalis

Streptococcus intermedius,

Streptococcus pyogenes,

Staphylococcus aureus

anaerobic bacteria

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DiagnosisDiagnosis

Viral URI’s symptoms: Rhinorrhea sneezing nasal airway obstruction facial congestion hyposmia sore throat cough eustachian tube dysfunction Fevers myalgias

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DiagnosisDiagnosis

Bacterial: The clinical signs and symptoms lack sensitivity (69%) and specificity

(64%). when a viral URI does not resolve after 10 days or is worsening at 5 to 7

days. signs and symptoms:

------nasal drainage

------facial pressure/pain

------decreased/absent olfaction

------fever, cough, fatigue, dental pain, and/or ear pressure.

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ComplicationsComplications

Orbital Complications Intracranial Complications

MeningitisEpidural AbscessSubdural AbscessIntracerebral Abscess

Preseptal CellulitisOrbital CellulitisSubperiosteal AbscessOrbital AbscessCavernous Sinus Thrombosis

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TreatmentTreatment

In the adult population with mild disease and no antibiotics in the prior 6 weeks

the following choices may be considered: amoxicillin/clavulanate, amoxicillin, cefpodoxime proxetil, cefuroxime axetil, or cefdinir

In patients with β-lactam allergies, trimethoprim-sulfamethoxazole, docycline, azithromycin, clarithromycin, erythromycin, or telithromycin may be used

Bacteriologic failure rates range from 20 to 25%. In those patients who have received antimicrobials in the prior 6 weeks, fluoroquinolones or higher dose amoxicillin clavulanate may be considered

Failure to respond to treatment within 72 hours requires a switch to another antimicrobial and/or reevaluation of the patient

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Treatment Treatment

In the pediatric population, the choices are similar to the adult population with 2 exceptions:

------dosing is based upon weight

------fluoroquinolones are not an option in the pediatric population

A 10-day treatment course with 1 of the above antimicrobials is recommended

An inappropriate antibiotic of insufficient duration may prolong infection and potentially morbidity of the disease.

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Chronic rhinosinusitis (CRS): is a clinical disorder

that encompasses a heterogeneous group of infectious and inflammatory conditions affecting the paranasal sinuses.

DefinitionDefinitionDefinitionDefinition

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There were 18.3 million patient office visits for CRS despite many patients not seeking medical attention.(2001)

CRS affects men and women equally, but subtypes of CRS appear to have different gender distributions. For example, CRS with NPs associated with aspirin-sensitivity has a female predominance of 2:1

Sinus disease is more common in the Midwest and South than in the northeast and western United States and the incidence is lower during the summer months compared to the other seasons.

EpidemiologyEpidemiologyEpidemiologyEpidemiology

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Sinusitis Sinusitis or or RhinosinusitisRhinosinusitis

Sinusitis was the commonly accepted terminology for

inflammation of the paranasal Sinuses

Now------ Sinusitis has gradually been phased out in

favor of rhinosinusitis because nasal inflammation

almost always coincides with inflammatory paranasal

sinus involvement.

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Anatomic Factors: Heller cells, silent sinus syndrome or a narrow frontal sinus ……

Mucociliary Dysfunction: ------Intrinsic factors leading to ciliary dysfunction include primary ciliary

dyskinesia or Kartagener syndrome.

------Extrinsic factors that disrupt mucociliary clearance include injury by environmental irritants, endogenous mediators of infl ammation, or surgical trauma.

Bone Inflammation: Bone may play an active role in the disease process and that, at a minimum; the

inflammation associated with CRS may spread through the Haversian system within the bone.

Biofilms: Recent investigations have found that bacteria such as P. aeruginosa form

biofilms in the sinuses that may lead to recalcitrant sinus disease……

CRS without NPCRS without NP------ ------ ETIOLOGY AND PATHOPHYSIOLOGYETIOLOGY AND PATHOPHYSIOLOGY

CRS without NPCRS without NP------ ------ ETIOLOGY AND PATHOPHYSIOLOGYETIOLOGY AND PATHOPHYSIOLOGY

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Allergic Fungal Rhinosinusitis:

Eosinophilic Chronic Rhinosinusitis

Ig E Independent Fungal Inflammation

Aspirin-Sensitive Nasal Polyposis

Bacterial Superantigen

CRS with NPCRS with NP------ ------ ETIOLOGY AND PATHOPHYSIOLOGYETIOLOGY AND PATHOPHYSIOLOGY

CRS with NPCRS with NP------ ------ ETIOLOGY AND PATHOPHYSIOLOGYETIOLOGY AND PATHOPHYSIOLOGY

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SymptomsSymptoms

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SymptomsSymptoms

History of URI or allergic rhinitis, History of previous episodes of sinusitis

Pressure, pain, or tenderness over sinuses (Increased pain in the morning, subsiding in the afternoon)

Nasal obstruction or congestion, causing difficulty breathing through nose

Malaise, Low-grade temperature

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SymptomsSymptoms

Persistent nasal discharge, often purulent Postnasal drip Cough, worsens at night Mouthing breathing, snoring Sore throat, bad breath Headache Ear pain

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Clinical PresentationsClinical Presentations

Periorbital edema Cellulitis Nasal mucosa is reddened or swollen Percussion or palpation tenderness over a sinus Nasal discharge, thick, sometimes yellow or green Postnasal discharge in posterior pharynx Difficult transillumination Swelling or boggy pale turbinates

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EvaluationEvaluationEvaluationEvaluation

History and Physical Examination: Nasal obstruction, nasal congestion, and postnasal discharge

are the most common symptoms

Tenderness to palpation or percussion in the periorbital, forehead, or cheek areas.

Nasal Endoscopy:

allows the assessment of mucosal hyperemia, edema, the gross appearance and sites of origin of NPs, and septal deformities or other anatomic abnormalities impacting sinus drainage.

Laboratory: Allergy testing, Elevated IgE……

Radiology: coronal CT scan, MRI

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DiagnosisDiagnosis

Nasal endoscopyImaging studies (CT scanning)Nasal and sinus culturesAn allergy test

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Anterior group: Maxillary

Anterioe ethmoid Middle meatal

Frontal

Posterior group :Sphemoid Sphenoethmiodal recess Olfacotory cleft

Posterioe ethmoid Supper meatal Sign Pus : Middle meatal Anterior sinus

Olfacotory cleft Posterior sinus

DiagnosisDiagnosis

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Complications of SinusitisComplications of Sinusitis

Ear infection Asthma flare upsOrbital cellulitis or abscess, Vision problemsMeningitis, Brain abscessCavernous sinus thrombosisSubdural empyema

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Antimicrobial Therapy

Systemic Corticosteroid Therapy

Topical Corticosteroid Therapy

Antileukotriene Therapy

Other Medical and Ancillary Therapies

ManagementManagementManagementManagement

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Avoid upper respiratory infections Carefully manage your allergies Avoid cigarette smoke and polluted air Use a humidifier

PreventionPreventionPreventionPrevention

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Endoscopic Sinus SurgeryEndoscopic Sinus Surgery

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What is ESSWhat is ESS

Endoscopic sinus surgery ------ is a procedure used to remove blockages in the sinuses .

This surgery does not involve cutting through the skin, as it is performed entirely through the nostrils. Therefore, most people can go home the same day.

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Advantages Advantages

Is less painful Leaves no visible scars Causes less bleeding Creates less discomfort after surgery Requires less packing in the nose after surgery Has a faster recovery period Has a higher success rate

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Surgical TechniqueSurgical Technique

UncinectomyEthomoidectomySphenoidotomy with EthomoidectomyFrontal Recess Surgery (Draf Type 1)Frontal Sinusotomy (Draf Type 2)Maxillary Antrostomy

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Postoperative CarePostoperative Care

Medical therapy-----antibiotic, saline spray, oral steroids……

Local management of the postoperative cavity: -----remove nasal package (48 h after operation) -----nasal endoscopy and cleaning of the cavity (around 1 week after operation)

Follow up-----at least 6 months!

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20092009 年年 66 月月 11日日

Follow up after ESSFollow up after ESS

20082008 年年 1010 月月 88日日

20082008 年年 99 月月 88日日

20082008 年年 88 月月 1818日日

20082008 年年 77 月月 3131日日

20082008 年年 77 月月 1414日日

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ComplicationsComplications

Hemorrhage CSF leakOrbital injuryNasolacrimal duct injuryRecurrence

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pituitary adenoma pituitary adenoma resection resection

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adenoidal hypertrophy

Adenoidectomy Adenoidectomy

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