The Medical Management of The Medical Management of Infective & Allergic RhinitisInfective & Allergic Rhinitis

Joe Marais FRCS(ORL)Joe Marais FRCS(ORL)www.the-nose.infoHillingdon Hospital,Hillingdon Hospital,

Northwick Park Hospital,Northwick Park Hospital,Bishops Wood HospitalBishops Wood Hospital

Clementine Churchill Hospital,Clementine Churchill Hospital,Harrow, London.Harrow, London.

I.I. Infective RhinosinusitisInfective Rhinosinusitis

Very common (10-15% of population)Very common (10-15% of population) Most viral (>200 species!)Most viral (>200 species!) Secondary bacterial infection (5-15%)Secondary bacterial infection (5-15%) Increasing incidenceIncreasing incidence

Definitions in SinusitisDefinitions in SinusitisInternational Rhinosinusitis Board 1997International Rhinosinusitis Board 1997

AcuteAcute Recurrent Recurrent AcuteAcute

ChronicChronic Chronic c. Chronic c. exacerbationsexacerbations

Rapid onsetRapid onset 2-4 episodes/year2-4 episodes/year Duration >12/52Duration >12/52 Worsening of existing Worsening of existing chronic symptomschronic symptoms

Duration<12/52Duration<12/52 Symptom-free for Symptom-free for >8/52 between >8/52 between attacksattacks

Persistent Persistent radiological changes radiological changes despite adequate Rxdespite adequate Rx

Resolution of acute Resolution of acute flare-ups, but not flare-ups, but not chronic symptomschronic symptoms

Complete ResolutionComplete Resolution Complete ResolutionComplete Resolution

between attacksbetween attacks

No Resolution.No Resolution.

Constant symptomsConstant symptoms

Symptoms variable, Symptoms variable, but always present.but always present.

Acute SinusitisAcute Sinusitis

Recurrent Acute SinusitisRecurrent Acute Sinusitis

Chronic SinusitisChronic Sinusitis

Acute-on-Chronic SinusitisAcute-on-Chronic Sinusitis

Microbiology of Acute Sinusitis Microbiology of Acute Sinusitis

Majority due to viruses (200 species !)Majority due to viruses (200 species !) Sinus changes on CT in >90% of URTI’sSinus changes on CT in >90% of URTI’s Many asymptomatic casesMany asymptomatic cases Changes mainly due to viscid secretions, Changes mainly due to viscid secretions,

not mucosal thickening per se.not mucosal thickening per se. Ciliary paralysisCiliary paralysis 5-15% secondary bacterial infection rate5-15% secondary bacterial infection rate

Microbiology of Microbiology of AcuteAcute Sinusitis Sinusitis

Varies with geographic region, age and Varies with geographic region, age and sampling techniquesampling technique

Strep.pneumoniae & Haemophilus Strep.pneumoniae & Haemophilus influenzaeinfluenzae 50% 50%

Gram Negatives 10%Gram Negatives 10% StaphlococcusStaphlococcus 6% 6% Rest incl. Rest incl. Moraxella, Branhamalis, Moraxella, Branhamalis,

S.pyogenesS.pyogenes..

Microbiology of Microbiology of ChronicChronic Sinusitis Sinusitis

Multi-organism infection more commonMulti-organism infection more common Gram –’ves more common Gram –’ves more common

(Pseudomonas,Klebsiella,Proteus) up to (Pseudomonas,Klebsiella,Proteus) up to 30%30%

Controversy re anaerobes: 12-90%Controversy re anaerobes: 12-90%

Gr +Gr -

StaphOther

Acute

Chronic0

5

10

15

20

25

30

35

40

45

50

%

Relative Frequency of Infecting Organisms

Acute

Chronic

Mechanisms of InflammationMechanisms of Inflammation

Abnormal mucociliary functionAbnormal mucociliary function Pathogen adherencePathogen adherence Inflammatory mediators: Histamine, PAF, Inflammatory mediators: Histamine, PAF,

Bradykinin, Il-4, Il-5, Il-13 etcBradykinin, Il-4, Il-5, Il-13 etc Cellular infiltratesCellular infiltrates OedemaOedema Ostium obstructionOstium obstruction

Why have I got “Sinus”, Doctor?Why have I got “Sinus”, Doctor?

Mucosal and ciliarydamage

Ciliary paresis

2°bacterial infection

Mucus stasis

VIRAL URTI

Goals in ManagementGoals in Management

Eradicate infectionEradicate infection Decrease durationDecrease duration Prevent ComplicationsPrevent Complications

Complications in SinusitisComplications in Sinusitis

ChronicityChronicity Acute orbitAcute orbit Intra-cranial sepsisIntra-cranial sepsis

Therapy for acute sinusitisTherapy for acute sinusitis

Local microbiological data importantLocal microbiological data important Middle meatal swabMiddle meatal swab Empiric treatmentEmpiric treatment Co-amoxiclav ( Cefuroxime / Clarithromycin)Co-amoxiclav ( Cefuroxime / Clarithromycin) Decongestant (Xylometazoline)Decongestant (Xylometazoline) Anti-inflammatory analgesia (Voltarol)Anti-inflammatory analgesia (Voltarol) Mucolytic (?)Mucolytic (?) Consider change at 48hr.Consider change at 48hr. Failure to respond: Refer ? consider lavageFailure to respond: Refer ? consider lavage

Therapy for Chronic SinusitisTherapy for Chronic Sinusitis

Many inadequately treated at presentationMany inadequately treated at presentation Try Clarithromycin x 12/52 nb. Down-regulation of Try Clarithromycin x 12/52 nb. Down-regulation of

inflammatory mediatorsinflammatory mediators If not, try Ciprofloxacin and MetronidazoleIf not, try Ciprofloxacin and Metronidazole Combine with decongestant, nasal topical steroid, Combine with decongestant, nasal topical steroid,

NSAID and douchingNSAID and douching Prolonged treatment usually necessary.Prolonged treatment usually necessary. Refer those with recurrent or persistent Sx.Refer those with recurrent or persistent Sx. Warn patient that surgery may be requiredWarn patient that surgery may be required

What can I do to reduce referral rate?

Don’t dismiss as a recurrent common cold! Irrigation of Nose with Saline (Neilmed) Long-term (3 months) antibiotic (eg

clarithromycin).nb non-compliance. Nasal steroid sprays Failure mandates referral

Surgical Treatment of Chronic Sinusitis

Open middle meatal drainage pathway

Allow mucociliary regeneration

Managed endoscopically

Offwork +/- 10days Prognosis good

Post-op ESS