MWeximelViedicaliiherapy’” for chronic rhinosinusitis Dr Leong Jern-Lin Fellow of American Rhinological Society PU Ta Teele RW eV eCT TN ot) ore C Ta lela Ta Mielec hae GroupPrimary FESS . FESS may not provide ans clatel ea tals - Significant worse outcome? 5 my, Pe eye iciee Kt ne) Ke oes | Re : = Additional disease in 2 or more as y) dependant sinuses in each side , = Diffuse polyps y Kennedy DW: Laryngoscope 1992, 102;1-18Revision FESS « Up to 11.4% has Revision FESS within 3 years! - Interval between surgeries = Average 11.8 to 33.5 months = Range 0.7 — 72.4 months Hopkins C et al. Clin Otol 2006, 31:390-398 pes yA Ue kee ype teh ee aot Pee) rrMax medical therapy - Using combination of agents « Suppress symptoms of chronic sinus disease + Culture-directed antibiotics when possible = Min 3 to 4 weeks = To prolong or repeat if respond « Topical steroid to be given with antibiotics * Topical decongestant may be given initially 3 to 5 daysMax medical therapy - Concept + Well Known to Rhinologists - Elusive & poorly defined concept + Lack of clinical’ studies to address the sus aRole of medical therapy . Helps define chronic and recurrent Sits - Helps‘CT interpretation - Preoperative optimizationMedical therapy aids in radiographic diagnosis of CRS - Sinus Gj scans = should only be obtained after maximal medical therapy = not all sinus.opacification on CT has surgical significanceAntibiotics in CRS *CRS = primarily medical disease = surgical cure of disease elusive « Preoperative period = reduce bacterial load - Postoperatively = prevent infection of static secretions = mucociliary transport restored Gwaltney JM Jr. Sinusitis: pathophysiology and treatment. 1994. p. 41-56 Anand VK et al. Otolaryngol Head Neck Surg 1997;117:S50-2‘Table 13-2 Commonly Used Broad-Spectrum Antibiotics Meet criteria Amoxicillin-clavulanate (Augmentin) Cefuroxime axetil (Ceftin) Cefpprotil (Ceftil) Loracarbef (Lorabid) Cefixime (Suprax) ‘Trimethoprim-sulfamethoxazole (Bactrim, Septra) Cefaclor (Ceclor) Erythromycin.sulfisoxazole (Pediazole) Doxycycline (Vibramycin) (Clarithromycin (Biaxin) Aszithromycia (Zithromax) Do not meet criteria” Ciprofiexacin (Cipro) Norfloxacin (Noraxin) Offoxacin (Flo: Cephalexin (Keflex) Cefadroxil (Duricef) Adapted from Poole MD. Selecting an oral broad-spectrum antibiotic. Ear Nose Throat J 1992;71:444-5, “Azena in this catezory cannot be wied alone. but combination therapy (suchRole of antibiotics - Role not universally accepted + ? Optimal duration * 6 weeks needed for resolution in Paediatric cases ~ Melzer — 30% recurrence after completing 3 wk Amox/Clav - Huck— 56% noted improvement after 10 eine be CT oe BO ran nse Be erase Huck W. Arch Fam Med. 1993-2-497-503Corticosteroids - CRS disease = immunologically complex inflammatory disease = not simply an infection * Therapeutic agents other than antibiotics should be utilisedMechanism of action « Affect inflammatory cell number and function + Systemic application = reduce circulating basophil, eosinophil, and monocyte counts to about 20% of normal = Lymphocyte counts -T & B cells reduction (T>B cells) ee olen eel meee eee oh] Elle] use in allergic diseases. In: Middleton E et al editors Nie principles and practice. 4th Ed. St. Louis: CV Ley AR ck oc)Summary - Steroid effects Table 13-5 Steroid Effects in Rhin. Inhibition of the secretion of growth factors and other mediators of inflammatory cell proliferation Inhibition of the release of arachidonic acid metabolites Inhibition of the accumulation of leukocytes in affected tissues Decreased vascular permeability Inhibition of nuropeptide-mediated responses Alteration in the secretion of glycoconjugates Adapted from Schleimer RP. Glucocorticoids: their mechanism of action and tise in allergic diseases. In: Middleton E, Reed CE, Ellis EF, et al., editors. Allergy: principles and practice. 4th Ed. St. Louis: CV Mosby. p. 912-4.Adverse Reactions and Precautions for Oxymetazoline Use Adverse _ transient burning Stinging _ Sneezing i ‘ Increased nasal discharge or dryness of nasal #QERRTASADE ae te emer go teem a me Gee HH SOT SSrrraire reste. Cngers Pe tne dresser meray mvaryomariow esata ert. 2025 Arma Aaget LT, ‘eed pat 1 3013.PhePaediatric acute rhinosinusitis management scheme for Primary Care DOT PES che of wren shoud be nasal cosrecten| Dr Guccioted Scrape ‘front pan, head comh ceartuon actene: mreweey XeeayCT not recommended