Intranasal Corticosteroids in Management

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DISUSUN: JESSICA GABRIELLE IDNANI (FK UKRIDA) ANDRIANI KEMALA SARI (FK UPN) PEMBIMBING : DR. KHAIRAN IRMANSYAH, SP. THT-KL, M.KES Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis

description

Rhinosinusitis

Transcript of Intranasal Corticosteroids in Management

  • DISUSUN:JESSICA GABRIELLE IDNANI (FK UKRIDA)ANDRIANI KEMALA SARI (FK UPN)

    PEMBIMBING :DR. KHAIRAN IRMANSYAH, SP. THT-KL, M.KESIntranasal Corticosteroids in Managementof Acute Sinusitis: A Systematic Review andMeta-Analysis

  • IntroductionAcute sinusitis is common condition, affecting an estimated 31 million Americans annuallyThe effectiveness of other treatments such as decongestants and antihistamines is largely unknownCurrently, it is not clear whether corticosteroids offer significant benefits for patients with acute sinusitis

  • Sinusitis ClassificationDefinitionsAcuteSx & signs of infectious process < 3 weeks durationSubacuteSx & signs 21 to 60 daysChronic> 60 days of sx & signsOr, 4 episodes of acute sinusitis each > 10 days in a single year

  • Sinusitis PathogenesisBasic cause is osteomeatal complex (the middle meatal region & the frontal, ethmoid, & maxillary sinus ostia there) inflammation & infectionSinus ostia occludedColonizing bacteria replicateCiliary dysfunctionMucosal edemaLowered PO2 & pH

  • Development of the maxillary sinus (numbers are age in years)

  • SinusitisEtiologic Organisms (& % incidence)Aerobic bacteriaStrep. pneumoniae (30)Alpha & beta hemolytic Strep (5)Staph. aureus (5)Branhamella catarrhalis (15 to 20)Hemophilus influenzae (25 to 30)Escherichia coli (5)Anerobes (10 % acute, 66 % chronic)Peptostreptococcus, Propionobacterium, Bacteroides, FusobacteriumFungi (2 to 5)Viruses (5 to 10)

  • Acute Sinusitis Usual Clinical PresentationSymptoms progress over 2 to 3 daysNasal congestion & discharge (usually thick & colored, not clear)Localized pain +/- referred painTenderness or pressure sensation over sinusesHeadacheCough due to postnasal dripHalitosis Malaise

  • Usual Physical Findings With Acute SinusitisErythematous edematous nasal mucosaPurulent secretions in middle meatal areaMay be absent if ostia completely blockedPercussion tendernessOver the involved sinusesOver the maxillary molar +/- premolar teethHalitosis+/- fever

  • Pain Patterns with Acute SinusitisMaxillary sinusitisUnilateral pain over cheekboneMaxillary toothachePeriorbital painTemporal headachePain worse if head uprightPain better if head supine

  • Pain Patterns with Acute SinusitisEthmoid sinusitisMedial canthal painMedial periorbital or temporal headachePain worsened by Valsalva or if supineSphenoiditisRetroorbital, temporal, or vertical headacheOften deep seated headache with multiple fociPain worse supine or bending forwardFrontalFrontal headachePain worse supine

  • Signs of Potentially Dangerous Complications of Acute SinusitisPeriorbital, frontal, or cheek edemaProptosisOphthalmoplegiaPtosisDiplopiaMeningeal signsNeuro deficits of cranial nerves II to VI

  • Goals of Medical Therapy for Acute SinusitisControl InfectionFacilitate sinus ostial patency and drainageProvide relief of symptomsEvaluate and treat any predisposing conditions to prevent recurrences

  • General Treatment for Acute SinusitisOral antibioticTopical and systemic decongestantsPain medicationsOptional or secondary medications:Guaifenesin (1200 mg po q 12h)warm nasal saline irrigations qidAntihistamine orally : only in the small % of patients with true allergic component

  • Use of Topical DecongestantsEphedrine sulfate 1 % 2 sprays each nostril q 4hPhenylephrine HCl 0.25 to 0.5 % 2 sprays q 4hOxymetazoline HCl 0.05 % 2 sprays q 12h

    Limit use to 3 to 5 days to avoid rebound vasodilatation and "rhinitis medicamentosa"

  • Use of Oral DecongestantsPhenylpropanolamine HCl 12.5 mg po q 4h or 75 mg q 12h (now not available in U.S.A.)Pseudoephedrine HCl 60 mg po q 6h or 120 mg q 12h

    Usually should be continued for 4 weeks

  • Treatment of Frontal SinusitisUsually should be admitted for initial IV antibiotic RxHigher incidence of intracranial complicationsGive IV Cefuroxime 2 gm IV q 8h or Ceftriaxone 2 gm IV q d and decongestantsIf not resolving in 24 to 48 hours of Rx may need surgical intervention ( frontal sinus trephination or external sinusectomy)

  • MethodsWe included in our meta-analysis RCTs that compared intranasal corticosteroids with placebo in children or adults settings. We excluded studies examining patients with chronic/allergic sinusitis and other that have underlying health condition.

  • MethodsWe searched MEDLINE, EMBASE, the CochraneLibrary including the Cochrane Central registerof Controlled Trials (CENTRAL), the Database ofReviews of Effectiveness (DARE), and the NationalHealth Service Health Economics Database fromthe beginning of each database until February 2011

  • MethodsUsing methodologic quality.Quality was assessed using :the criteria of allocation concealment,randomizationcomparability of groups at baseline, blinding, treatment adherence,percentage participation.

  • Results

  • DiscussionThis systematic review demonstrates that intranasal corticosteroids offer a small but signifi cant symptomatic benefit in acute sinusitislonger durations of treatment (21 days) and higher doses of the medication.facial pain and nasal congestion may be most responsive to intranasal corticosteroids

  • Comparison With Existing LiteratureThe small benefi t of intranasal corticosteroids for the broad measure of symptom resolution or improvement at 14 to 21 days was similar in direction and sizeto that found in a recent Cochrane reviewlarger effect sizes in subgroup analyses by dose and timing of outcome measure