GUIDELINE Sinusitis. David M. Poetker MD, MA Associate Professor. Division of Rhinology and Sinus Surgery

Transcription

1 GUIDELINE Sinusitis David M. Poetker MD, MA Associate Professor Division of Rhinology and Sinus Surgery

2 Guideline Fokkens et al. The European Position Paper on Rhinosinusitis and Nasal Polyps Rhinology Supplement 23: page behemoth Cumbersome document Some clear recommendations, others not so clear Some with levels of evidence, others without Some with Grades of recommendation, others without Limited discussion to Adults

3 Categories of Evidence Ia Evidence from meta-analysis of RCTs Ib Evidence from at least one RCT IIa Evidence from at least one controlled study IIb Evidence from a quasi-experimental study III Evidence from non-experimental study, such as Comparative, correlation and case control studies IV Evidence from expert committee report/opinion

4 Strength of Recommendation A B C D Directly based on category I evidence Directly based on category II evidence or extrapolated recommendations from Cat I evidence Directly based on category III evidence or extrapolated recommendation from Cat I or II evidence Directly based on Category IV evidence or extrapolated recommendation from Cat I, II, or III evidence

5 BACKGROUND Rhinosinusitis in adults Inflammation of the nose and paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior) ± facial pain/pressure ± reduction or loss of smell And either endoscopic signs or CT changes Polyps, purulence, edema Mucosal changes, OMU obstruction

6 Acute Rhinosinusitis Acute Rhinosinusitis (ARS) in adults Acute onset of two or more symptoms, one of which should be either nasal blockage/obstruction /congestion or nasal discharge (anterior/posterior) ± facial pain/pressure ± reduction or loss of smell For < 12 weeks With symptom free intervals if the problem is recurrent

7 Case Report JK is a 34 year old female with chief complaint of sinus infection Started 2 weeks ago as a cold Now with nasal congestion, thick drainage, facial pressure Smells garbage after blowing her nose Using OTC cold and sinus tablets

8 What would you consider the next step? A. Antibiotics B. Nasal Endoscopy C. CT Scan D. Saline Irrigations 0% 0% 0% 0% A. B. C. D.

9 Nasal Endoscopy Useful to visualize anatomy and obtain swab Middle meatal culture has a reasonable correlation to maxillary puncture Level IIb evidence Relatively high specificity, but low sensitivity

10 CT scan CT may be considered in very severe disease, immuno-compromised patients, or when there is suspicion of a complication

11 Clinical Consensus Statement: CT AAO-HNS Clinical Consensus Statement: Appropriate use of computed tomography for paranasal sinus disease 33 consensus statements reached 11 addressed medical management of sinusitis 5 relevant to current slides Setzen, et al. Otolaryngol Head Neck Surg 2012;147:

12 Clinical Consensus Statement: CT CT imaging is indicated in patients: Not responding appropriately to medical management 12 experts 92% Agreement with this statement

13 Clinical Consensus Statement: CT CT imaging is indicated in patients: Treated repeatedly for presumed sinusitis With persistent complaints post-treatment No clinical evidence of sinusitis To confirm no sinonasal pathology To avoid continued inappropriate antibiotics 12 experts 100% agreement with this statement

14 Clinical Consensus Statement: CT CT imaging is not indicated for clinically diagnosed, uncomplicated ARS 12 experts 92% Agreed, 83% strongly agreed CT imaging is indicated for recurrent acute and chronic sinusitis 12 experts 92% Agreed, 83% strongly agreed

15 Clinical Consensus Statement: CT Plain X-rays and US are not recommended in the evaluation of sinusitis 12 experts 83% agreed with this statement

16 Antibiotics Rhinosinusitis is the 5 th most common diagnosis for which antibiotics are given 21% of all adult antibiotics are for ARS Use in mild, moderate or uncomplicated ARS has been shown to be NOT useful Moderate improvements in studies Not recommended by most guidelines

17 Antibiotics No specifics on Indications provided Recommend reserving for severe ARS High fever, severe pain Weigh the moderate benefits against potential adverse events Start with a narrow spectrum agent S peumo, H flu

18 Intranasal Corticosteroids Monotherapy or as adjuvant to antibiotics Cochrane review Favors use Level of Evidence: Ia No mention of severity of disease

19 Nasal Irrigation Systematic Review of literature Nasal douching with saline solution has a limited effect in adults with ARS Level of Evidence: Ia

20 Oral Corticosteroids Adjunctive therapy to oral antibiotics Cochrane review Oral corticosteroids are effective for short term relief of symptoms (headache, congestion, etc) Level of Evidence: Ia

21 Chronic Rhinosinusitis Chronic Rhinosinusitis (CRS) in adults Without nasal polyps (CRS) With nasal polyps (CRSwNP) Presence of two or more symptoms, one of which should be either nasal blockage/obstruction /congestion or nasal discharge (anterior/posterior) ± facial pain/pressure ± reduction or loss of smell For 12 weeks

22 Case Report KJ is a 43 year old male with chief complaint of sinusitis 10+ year history of sinus problems Daily nasal congestion, thick drainage, facial pressure Little to no sense of smell Uses nasal steroid sprays and saline irrigations

23 What would be your next step? A. Nasal swab B. Sinus trans-illumination C. Plain sinus x-ray D. Nasal endoscopy 0% 0% 0% 0% A. B. C. D.

24 Nasal swabs CRS Work up Reasonable correlation with middle meatal cultures and maxillary sinus punctures Level IIb evidence Sinus Trans-Illumination Insensitive and non-specific Unreliable diagnostic test

25 Nasal Endoscopy CRS Work up Significantly better illumination and visualization Added utility in the diagnosis of CRS Does not correlate with symptoms post-ess Relatively high specificity but low sensitivity

26 Plain Sinus X-Rays CRS Work up Pro: cheap, easy access Con: limited usefulness Current radiologists don t know how to read* EPOS / AAO-NHS CCS: Not recommended CT scans Modality of choice for sinuses

27 Case Report KJ s nasal endoscopy demonstrates diffuse mucosal edema and thick mucus vs mucopus CT scan is read as diffuse mucosal thickening but no air-fluid levels Lund Mackay score is 9

28 Which of the following treatments would you consider in JK? A. Alternative topical steroid preparations B. Oral corticosteroids C. Oral or Topical antibiotics D. Topical washes, other 0% 0% 0% 0% A. B. C. D.

29 Topical Steroids Statement: INCS improve symptoms and patient reported outcomes in CRS Level of Evidence Ia Grade of Recommendation A Statement: Delivery of INCS directly to sinuses brings about a greater effect Level of Evidence Ia Grade of Recommendation A

30 Nasal Irrigations Statement: Nasal douches are recommended for CRS Level of Evidence: Ia Grade of Recommendation: A

31 Oral Corticosteroids Statement: Systemic steroids benefit CRS Level of Evidence IV Grade of Recommendation C No data for or against the use

32 Oral Antibiotics Statement: Short-term treatment in CRS is probably only relevant in exacerbations with a positive culture. Level of Evidence: II Grade of Recommendation: B No placebo controlled trials available

33 Oral Antibiotics Statement: Long term (>4 weeks) use of a macrolide benefit all CRS patients Level of Evidence: Ib Grade of Recommendation: C In CRSsNP patients with normal IgE Grade of Recommendation: A

34 Topical Antibiotics Statement: Topical antibacterial therapy CANNOT be recommended in the treatment of CRS Level of Evidence: Ib Grade of Recommendation: A 3 controlled studies show no benefit over saline

35 Topical Antifungals Statement: Nasal amphotericin B treatment in CRS is not recommended Level of Evidence: Ib Grade of Recommendation: A

36 Short term antibiotics CRSwNP Level of Evidence: Ib Grade of Recommendation: C One RCT doxy had a small effect on polyps size and PND Long term antibiotics Level of Evidence: III Grade of Recommendation: C Some benefit on symptoms and polyp size

37 CRSwNP Anti-Mycotics Topical Ampho-B is NOT recommended Grade of Recommendation: A Systemic antifungal is NOT recommended Grade of Recommendation: A

38 Summary of Guidelines

39 Strong Recommendation Grade A Topical steroids for CRS Nasal irrigations for CRS Long term macrolides for CRS, NORMAL IgE

40 Recommendation Grades B, C Topical steroids for ARS Nasal irrigations for ARS Oral steroids for ARS Oral steroids for CRS Short term antibiotics for CRS Long term antibiotics for CRS

41 Strong Recommendation Against Topical antibiotics for CRS Topical anti-fungals for CRS or CRSwNP Systemic anti-fungals for CRSwNP