Management Rhinosinusitis in chiIdren.pptx
- 2. DEFINITION • Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). • 5–13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. • Though not life threatening, it profoundly affects child's school performance and sleep pattern. • If untreated, it could progress to chronic rhinosinusitis (CRS)
- 3. Classification • Acute : < 1 months • Subacute : 1 – 3 months • Chronic : >3 months
- 4. Clinical signs • Acute rhinosinusitis implies sudden onset of two or more of the following symptoms: nasal discharge, stuffiness or congestion, facial pain/pressure, or anosmia/hyposmia
- 5. Cause of “ostiomeatal complex” obstruction 1. anatomic abnormalities such as adenoidal hypertrophy, deviated nasal septum, concha bullosa, etc 2. mucosal edema due to viral rhinitis and allergic rhinitis including aspirin sensitivity; 3. nonallergic rhinitis (vasomotor rhinitis, rhinitis medicamentosa, cocaine abuse); 4. nasal polyps; 5. unattended nasal foreign bodies; 6. immunodeficiency conditions (congenital or acquired), these comprise 1/3rd-2/3rd of cases of refractory chronic sinusitis; 7. cystic fibrosis; 8. ciliary dysfunction syndromes such as primary ciliary dyskinesia, Kartagener's syndrome, and so forth; 9. Prolonged ventilation, NGT, smoking, GERD, nasal tumor, periodontitis etc
- 6. Pathogen causes • Viruses are most common causes of acute rhinosinusitis. • Within few days, bacterial invasion and proliferation set in (5- 10% of rhinosinusitis will develop to bacterial infection. • Streptococcus pneumonia, Hemophilus influenzae, Moraxella catarrhalis, beta-hemolytic Streptococcus pyogenes are usual pathogens cultured. Mycoplasma and chlamydial species have also been found associated with sinusitis in children
- 7. Acute Rhinosinusitis Bacterial (ARSB) • The IDSA guidelines suggest that ABRS can be diagnosed with each of the following clinical scenarios: 1. URI symptoms lasting more than 10 days without any improvement; 2. Severe onset of signs and symptoms lasting more than 3-4 consecutive days,like high grade fever (>39°C),facial pain or purulent nasal discharge; 3. Worsening of signs and symptoms following a typical viral URI that lasted 5-6 days and were initially improving, like new onset of fever, headache, or increase in nasaldischarge“double- sickening”.
- 9. Work up • Transillumination of sinuses is useful in hands of experienced person. In this, a flashlight is placed against the patient's cheek and the doctor looks into the patient's open mouth. • A lit-up reddened area is seen in the palatal area with normal sinuses. When sinuses are fluid-filled, this reddened area will not be visualized. • Near-infrared light (750–1100 nm) can penetrate deeper and permit enhanced illumination of deeper structures. But since this light is invisible normally, a charge-coupled device camera is used to capture and record images. This technique has been found to be a safe, reliable, low-cost, and simple aid for diagnosis of sinusitis.
- 10. Radiology • Plain radiography of paranasal sinuses can be performed, but it has a limited diagnostic role. Water and Caldwell-Luc's views are taken for sinusitis. Haziness, opacification, or fluid level is suggestive of sinusitis. • CT scan of sinuses gives a better visualization and is a useful tool preoperatively. • Contrast is reserved for suspected suppuration. CT scan can pick up noninvasively ostiomeatal anomalies with great accuracy. Mucosal changes, intrasinus collections or growths, and adjacent bone changes can be visualized..
- 11. Management • An acute attack of rhinosinusitis is usually self-limiting and recovers with symptomatic treatment and with minimal intervention. • Steam inhalation, adequate hydration, instillation of topical decongestants, warm facial packs application, and saline nasal drops are useful. • Elevation of head while sleeping gives relief. • The nasal decongestants decrease mucus production and can be safely used for 5–7 days. • Extended use beyond this period may lead to rebound vasodilatation and worsening of nasal stuffiness
- 12. • The saline irrigations assist to mechanically clear secretions, minimize bacterial and allergen burden, and improve mucociliary function. • Nasal steroidal or cromolyn drops or sprays improve symptoms in children with concurrent nasal allergy. • Antihistamines are beneficial in those with associated nasal allergy. But they have a tendency to inspissate the secretions and further worsen rhinitis and ostial obstruction. • Antibiotics are usually not warranted. A “wait-and-watch” policy for 7–10 days is fruitful and cost-effective. About 90% recover without antibiotics in a week
- 13. 1. Respiratory allergy : - Allergen avoidance - Environmental control - Topical nasal steroids - Second-generation antihistamine - Leukotriene receptor antagonist, and immunotherapy are common measures to control allergic rhinitis. *Immunotherapy is valuable for children with known allergens that cannot be avoided and where conservative therapy has not been advantageous. Anti-IgE therapy has been found to provide clinical benefit in patients with seasonal allergic rhinitis.
- 14. 2. Gastroesophageal reflux. - H2-blockers, prokinetic agents, and hydrogen ion pump inhibitors are used to control reflux. 3. Cystic fibrosis - Nasal irrigations, nasal steroids, antibiotic courses, nebulized antibiotics, chest physiotherapy, and exercises aid to clear the copious secretions.
- 15. Treatment • Acute rhinosinusitis • High-dose amoxicillin (90 mg per kg per day) should be considered as a first-line agent for the treatment of sinusitis because of its activity against sinus pathogens. • Because the proportion of cases caused by Haemophilus influenza is likely increasing and the rate of B-lactamase production by this organism is also increasing ,the addition of clavulanic acid to amoxicillin provides an advantage over amoxicillin alone. • Cephalosporins, although they are less active against S pneumonia than amoxicillin-clavulanate. For those children in whom amoxicillin-clavulanate or second or third generation cephalosporins fail, a combination of cefixime may be used as an alternative to the use of parenteral antimicrobialagents. • For patients in whom beta-lactam antibiotics are contraindicated, respiratory fluoroquinolones (levofloxacin or moxifloxacin) or doxycycline may be used.
- 16. Response evaluation • Response to therapy is rapid in children who have sinusitisand are adherent to therapy with an appropriate antimicrobialagent. Symptoms typically improve within 48 hours (i.e. fever, cough, discharge.). If symptoms worsen within 72 hours or are not improved within 3-5 days, then clinical reassessment is warranted.
- 17. Chronic rhinosinusitis • In pediatric CRS associated with allergic rhinitis, allergen avoidance, anti-histamines, and nasal steroids will help in ameliorating the symptoms. • Moreover, allergen immunotherapy may be an underused option that could benefit patients with persistent allergic rhinitis and can change the natural course of the disease by reducing the symptoms and medications use. • Surgical intervention is not the mainstay of treatment ofCRS and is only used in the presence of complications, in failure of medical treatment and in patients with suspected anatomic abnormalities.
- 18. Prognosis • Prognosis depends on stage of rhinosinusitis, associated conditions, rate of complications, type and severity of infection, host factors, environmental factors, compliance with treatment, and treatment modality employed. • Acute rhinosinusitis if managed well has potential to recover with no sequelae. • Recurrence rate would be lower if associated conditions are rectified simultaneously and negative environmental factors are eliminated