Sinusitis and Otitis Media for Primary Care Providers

Alicia R. Sanderson, MD LCDR, MC, USN Otolaryngology-Head and Neck Surgery Facial Plastics & Reconstructive Surgery

DeWitt Army Community Hospital Fort Belvoir, VA

DeWitt Health Care Network

Sinusitis-Objectives

Define Adult Rhinosinusitis and subtypes Review evidence based medicine Suggest a treatment algorithm Review appropriate antibiotic selection and adjuvant therapies

Definitions
Rhinosinusitis- symptomatic inflammation of
the paranasal sinuses and nasal cavity

Uncomplicated Rhinosinusitis- without

clinically evident extension of inflammation outside the paranasal sinuses and nasal cavity (no neurologic, opthalmologic or soft tissue involvement) Acute (<4 weeks)
Acute Bacterial (ABRS) or Viral (VRS)

Subacute (4-12 weeks) Chronic (>12 weeks)

Diagnosis-Acute
Up to 4 weeks of purulent nasal discharge with nasal obstruction and/or facial pain pressure ABRS vs VRS
ABRS when sxs are present for 10 days or more OR symptoms worsen within 10 days after initial improvement (double worsening)*

*Purulent discharge can occur in viral or bacterial infections

Evaluation-Acute
Imaging is NOT recommended in uncomplicated acute rhinosinusitis

Treatment-Acute
Symptomatic relief of VRS
analgesics/antipyretics Topical or systemic decongestants NO benefit systemic steroids or antihistamines

Symptomatic relief of ABRS

Analgesics Studies show benefit to use of topical Steroids Saline irrigations (isotonic or hypertonic) Some benefit to topical decongestant, xylometazoline (do not use >3 days) Mucolytics (guaifenesin) No data No benefit antihistamines

Treatment-Acute
Watchful Waiting of ABRS
observe without Abx up to 7 days after diagnosis Uncomplicated, mild illness (temp <38.3 C/101 F), assurance for follow-up Begin abx if fail to improve in 7 days or worsens Spontaneous improvement early Benefits of abx vs placebo at 7-12 days Adverse events greater in abx group (GI, rash, vaginal dc, HA, dizziness, fatigue) Unknown impact on bacterial resistance

Treatment-Acute
Antibiotic use for ABRS
Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis First line therapy: Amoxicillin or trimethoprimsulfamethoxazole or macrolide for PCN allergic in acute setting- Randomized Control Trials found no benefit to other stronger abx Amoxicillin is safe, effective, low cost and narrow spectrum Common duration 10 days

Treatment Failure ABRS

Sxs worsen or fail to improve by 7 days after diagnosis
Decreased susceptibility to antibiotic High-dose amoxicillin-clavulanate (4g/day) or Flouroquinolone (levofloxacin, mocifloxacin, gemifloxacin) Examine for complications

Sinusitis Antimicrobial Efficacy

Therapy Amoxicillin/clavulanate Amoxicillin Cefpodoxime TMP/SMX Doxycycline Azithromycin Gatifloxacin/levofloxacin Clindamycin Clinical efficacy 90-91% 87-88% 87% 83% 81% 77% 92% 92%

Antimicrobial Treatment Guidelines for ABR 2004, Otolaryngology-HN Surgery, January 2004

Diagnosis-Chronic
Nasal obstruction, facial congestionpressure, decreased sense of smell, purulent discharge for >12 weeks AND documented inflammation (edema, polyps, radiographic imaging) Recurrent Acute- Four or more episodes in one year with symptom free intervening periods

Rhinology-Exam
Exam
Polyps Septal deviation/spurs Rhinorrhea Assess air flow

Polyps

Polypoid changes

Septal spur

Evaluation-Chronic
Nasal Endoscopy-polyps, mucopurulent discharge, edema, anatomy Radiographic imaging-CT Sinus Gold Standard NO benefit during acute infection Allergy and Immunology Evaluation (AR in 4084% patients with CRS)

Comorbid factors-Chronic
Allergic rhinitis, cystic fibrosis, immunocompromised state (IgA, IgG, IgM, HIV), ciliary dyskinesia and anatomic variation

Treatment-Chronic
Preventive measures
Good hygiene, avoid smoking Saline irrigations (improved mucociliary ftn, decreased edema, rinse debris and allergens)

Antibiotic use for CRS

Treatment for 3-6 weeks Bacteria in ABRS less common, Staph aureus, S. epidermidis, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter spp, Escherichia coli

Antimicrobials for Rhinosinusitis Adults

Respiratory Quinolones (95%) HD Amoxicillin / clavulanate (94%) Ceftriaxone (94%) HD Amoxicillin (1.5-4 g/d) (90%) Cefpodoxime proxetil (88%) Cefuroxime axetil (85%) Cefdinir (83%) TMP/SMX (81%) Doxycycline (79%) Telithromycin (77%) Macrolides (73%) Placebo (47-62%)

More effective

Less effective

Source: Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg 2004;130(1Suppl 1):S1-45.

Treatment-Chronic
Adjuvant therapies
Smoking cessation Saline irrigations Nasal steroids Short course systemic steroids (two weeks)

Surgical Intervention

The Sinusitis Patient

Evaluate patient and proper diagnosis Consider the timing Treat symptoms Treat with appropriate antibiotics as indicated for adequate duration Obtain imaging only after adequate time and treatment or if suspected complication Consider modifying factors

Otitis Media
Define otitis media and subtypes Discuss natural course of disease Treatment recommendations and indications for surgical intervention

Otitis Media-definitions
Acute Otitis (AOM) Recurrent Acute Otitis (RAOM) Chronic otitis (COM) Otitis Media with Effusion (OME)

Otitis Media Diagnosis

AOM
Rapid/Recent onset signs/sxs or ME inflammation (erythema of TM, otalgia interferes with activity) AND Presence of MEE: bulging of TM, decreased TM mobility, air-fluid level in ME, Otorrhea

OME
Presence of MEE

Diagnosis Acute Otitis Media

Purulent, bulging TM Serous effusion can persist for up to 3 months Pneumatic otoscopy (88-99% sen, 56-90% spec) Tympanometry (54-96% sen, 73-93% spec)

Acute Otitis media

Serous effusion

Acute Otitis Media Treatment

Treatment of pain
Acetaminophen, ibuprofen Topical Benzocaine (Auralgan, Americaine Otic)

Observation of uncomplicated AOM

48-72hrs Age (6m-2y, >2y), severity (temp >39 C), certainty of dx Assurance of follow-up

Acute Otitis Media Observation

Age Certain Diagnosis
Antibacterial therapy

Uncertain Diagnosis
Antibacterial therapy

<6mo

6 mo 2y

Antibacterial therapy

Antibacterial therapy if severe, observe non-severe Observation option

>2y

Antibacterial therapy if severe, observe if not severe

Acute Otitis Media

By 24hr 61% improved +/- abx, by 7 days 75% resolved 12.3% reduction in clinical failure rate 2-7 days if tx amp or amox vs placebo *Delay tx 72hrs- 76% never need abx, immediate abx tx resulted in 1 day shorter illness & tsp/day less acetaminophen In children with more severe illness, abx tx has greater benefit No evidence for increased risk of complications with initial observation *UK

Otitis Media-Bacteria
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis Treatment
High dose Amoxicillin (80-90 mg/kg/day) first line High dose Amoxicillin/clavulanate (90mg/kg amox, 6.4mg/kg/day clavulanate) PCN allergy: cefdinir (14mg/kg/d), cefpodoxime (10mg/kg/d), cefuroxime (30mg/kg/d) , azithromycin (10mg/kg/d), clarithromycin (15mg/kg/d), clindamycin (30mg/kg/d) <6yo 10days, >6yo 5-7 days (weak evidence)

Otitis Media-Bacteria
If fails abx tx, change abx Ceftriaxone (50mg/kg/d) IV or IM for 3 consecutive days Tympanocentesis MEE persists for up to 3 months and does NOT need treatment

Recurrent Acute Otitis Media

Reduce risk factors
Avoid tobacco smoke exposure, eliminate pacifier after 6 months, day care Breastfeeding, immunizations protective

Tympanostomy tube placement

>3 episodes in 6 months >4 episodes in 12 months Complications Decrease rate of AOM 1 episode/child/yr or RR reduction 56%

Otitis Media with Effusion

Diagnosis with pneumatic otoscopy, tympanometry Document laterality, duration of effusion and severity of sxs Determine if child at risk for speech/learning difficulty and evaluate hearing, speech
Permanent hearing loss, language delay, autism, syndromes, visual impairment, cleft palate

Otitis Media with Effusion

Manage child with watchful waiting for 3 months from date of effusion or dx
75-90% of OME after AOM resolves by 3 months

Hearing testing when OME >3 months or language delay or sig hearing loss suspected Children not at risk should be monitored ever 3 to 6 months until effusion is gone Treatment is tympanostomy tube insertion (Adenoidectomy with second set of tubes)

Otitis Media with Effusion

No benefit to the use of antihistamines and decongestants Antimicrobials and steroids do not have long term efficacy

Indication for ENT referral

Complications of acute/chronic otitis media
facial nerve paralysis, meningitis, and intracranial and/or neck abscess formation

Conductive hearing loss in a patient with otitis media with effusion for > 3 months Otitis media with effusion with associated speech delay History of more than 3 episodes of otitis media in 6 months or more than ~4-5 episodes in 12 months Chronic retraction of the tympanic membrane

Summary Otitis Media

Onset and severity of symptoms Observation without abx in a healthy child with reassessment in 48-72hrs Treat symptoms High-dose Amoxicillin first line drug MEE persists for up to 3 months, document Monitor for hearing loss or speech delay Refer to ENT for MEE >3-6 months, hearing loss, speech delay, RAOM or complications

References
Rosenfeld, RM et al. Clinical practice Guideline:Adult Sinusitis. Otolaryngol Head Neck Surg. 2007. 137:S1-S31 Benninger, MS et al. Adult Chronic Rhinosinusitis: definitions, diagnosis, epidemiology, pathophysiology. Otolaryngol Head Neck Surg. 2003. 129:S132 AAP. Clinical Practice Guidelines: Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004. 113:1451-1465 Lieberthal, AS Acute Otitis Media Guidelines: Review and Update. Current Allergy and Asthma Reports. 2006. 6:334-341 Rosenfeld et al. Clinical Practice Guideline: Otitis Media with effusion. Otolaryngol Head Neck Surg. 2004. 130:s95-118 AAFP, AAO-HNS, AAP. Subcommittee on Otitis Media with Effusion. Pediatrics 2004. 113:1412-1429 Dietmer, T. Tympanostomy tubes: A review of recent studies. ENT Journal. 2004 83:7-9