Clinical Case
KP is a 24 year old male patient who presents to your pharmacy complaining of a headache and a very plugged nose. He has had these symptoms for the past 4 days. This morning, his nose also started
running, which he describes as a slightly green-coloured discharge. He says that he called the health line and the nurse he talked to suggested he make an appointment with his family physician, but he came to you instead.
What is your approach to this patient?
???
Paranasal Sinuses
What are Sinuses ?
What are the 4 pairs of Paranasal Sinuses & where are they located?
Sinuses are hollow air spaces in the body.
Paranasal sinuses (4 pairs):
- Frontal Sinuses
over the eyes in the brow area - Maxillary sinuses
inside each cheekbone - Ethmoid sinuses
just behind the bridge of the nose and between the eyes - Sphenoid sinuses
in the upper region of the nose and behind the eyes
Paranasal Sinuses (pictures)
Paranasal Sinuses and Turbinates (pictures)
see slide 5, 6
see slide 7
Drainage happens at top of sinus so if mucus ciliary apparatus is obstructed, it can be asy for bacteria or microorganisms to grow and cause inefction of sinuses
Paranasal Sinuses
What age do the 4 pairs develop in the body?
Maxillary and Ethmoid sinuses are present in infancy
Sphenoid sinuses are present by the third year and
develop up to 12 years of age
Frontal sinuses appear by the 5th year and develop
into adolescence
Paranasal Sinuses
What do Turbinates do?
Sinus characteristics?
Turbinates warm and humidify the air
Each sinus
- Has an opening to the nose (ostea)
- Joined with the nasal passages by a continuous mucous membrane lining
- Allows free exchange of air and mucous
- Produces a thin mucous that ‘washes’ over the sinuses via cilia
- Approximately 1 cup of mucous is produced each day and swallowed unnoticably
Epidemiology
Most common predisposing factor for acute rhinosinusitis is ?
Children have __ - __ viral upper respiratory tract
infections per year.
Rarely colds are complicated by acute _________ sinusitis (only 0.5-2% of cases) (<5% in children)
Most common predisposing factor for acute rhinosinusitis is a viral upper respiratory tract infection
Children have 6 – 10 viral upper respiratory tract infections per year.
Rarely colds are complicated by acute bacterial sinusitis
(only 0.5-2% of cases) (<5% in children):
- Ostia become obstructed due to inflammation from viral infections or allergens
- Cilia are rendered immotile by viruses and/or tobacco smoke
- Fluid and bacteria are trapped and may proliferate
Predisposing Factors
Medical conditions:
- Respiratory infections, allergic rhinitis, cystic fibrosis, immunodeficiency, Wegener’s syndrome
Irritants:
- Tobacco smoke, pollution, chlorine
Anatomic;
- Deviated nasal septum, enlarged adenoids, immotile cilia, polyps, tumours, foreign bodies
Medications:
- Overuse of intranasal decongestants, cocaine abuse
Trauma:
- Dental procedures, diving
Prevention
Limit spread of viral infections by handwashing
Avoid environmental tobacco smoke
Avoid allergen exposure
Regular influenza vaccinations
Symptoms
- Fever
- Nasal congestion
- Maxillary toothache
- Facial pain
- Facial swelling
- Headache
- Cough plays a more significant role in children
- The colour of the nasal discharge/sputum is related to the presence of neutrophils and should not be used to diagnose sinusitis
Diagnosis – Acute Sinusitis
Primarily history and physical
Diagnosis requires at least 2 Major Symptoms:
P – Facial Pain, Pressure/fullness
*O – Nasal Obstruction
*D – Nasal purulence/discolored postnasal Discharge
S – Hyposmia / anosmia (Smell)
*At least one symptom must be nasal obstruction (O) or
nasal purulence/discolored postnasal discharge (D). Thus diagnosis requires 2 PODS, one of which must be O or D.
Diagnosis – Acute Sinusitis
NOT helpful ?
- Routine X-rays not very helpful
- CT scans not very helpful in acute sinusitis
- Culture of nasal discharge not helpful
- Illumination of sinuses not helpful
Gold standard - puncture aspirate of sinus fluid
(not usually done unless failure of treatment)
Acute Bacterial Sinusitis - Pathogens
- S. pneumoniae —|
- –| > 50% - H. influenzae —|
- M. catarrhalis 20%
- Mixed anaerobes 10%
- Rarely S. aureus, S. pyogenes, aerobic Gram-negative
organisms - 20% have respiratory viruses (rhinovirus, influenza or
parainfluenza) alone or with bacterial pathogens
Resistance Patterns
S. pneumoniae Edmonton Community
see slide 17
Resistance Patterns
H. influenzae Edmonton Community
see slide 18
Bacterial Sinusitis – Clinical Presentation & Diagnosis
Differentiation between Bacterial and Viral Rhinosinusitis ???
- Persistent symptoms or signs compatible with acute
rhinosinusitis lasting ≥10 days without any evidence of
clinical improvement
If for at least 10 days, less proparable it is viral - Severe symptoms or signs of high fever (≥39 o C) (102 o F) and purulent discharge or facial pain lasting for at least 3-4 days at the beginning of the illness
- Worsening symptoms or signs characterized by the new onset of fever, headache or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and was initially improving (“double sickening”)
Management of Acute Sinusitis
- Analgesics
- Irrigation with normal saline
- Inhalation of steam
- Short duration (< 5 days) intranasal decongestants
- First generation antihistamines not recommended
- Second generation antihistamines may be
recommended if allergic component - Nasal corticosteroids – may be of benefit in recurrent
and/or allergic rhinosinusitis - Selective antibacterial therapy
Antibacterial Therapy
Benefit of antibacterials controversial (~ 70% resolve spontaneously)
- Some guidelines recommend high-dose amoxicillin-clavulanate initially instead of amoxicillin for first line treatment of sinusitis because of high rates of penicillin-reisistant S. pneumoniae and β-lactamase producing H. influenzae and M. catarrhalis
- In Canada amoxicillin is a reasonable first choice
- Lower resistance rates in Canada
- Amoxicillin has the best overall activity against
S. pneumoniae including penicillin-resistant strains - Higher incidence of diarrhea with clavulanic acid
Acute Sinusitis – Adults
Initial Therapy
Bugs & Drugs app
see slide 22
Acute Sinusitis – Adults
Failure of 1 st line
Bugs & Drugs app
see slide 23
Acute Sinusitis – Pediatric
Bugs & Drugs app
see slide 24
Acute Sinusitis – Pediatric
Failure of First Line Treatment
Bugs & Drugs app
see slide 25
-
Intro40
-
Clinical Lab Assays 121
-
Bacterial Pathogens Part I40
-
Bacterial Pathogens Part II40
-
Otitis Media 1.024
-
Otitis Media 2.025
-
Sinusitis21
-
Pharyngitis14
-
Pneumonia 1.034
-
Pneumonia 2.020
-
Penicillins37
-
Cephalosporins34
-
Carbapenems and Monobactams11
-
β-lactam Allergies28
-
Clinical Lab Assays 228
-
Pk-PD7
