Post on 17-Dec-2015
transcript
PEDIATRIC RHINOSINUSITIS
DANIEL W. TODD, MD, FACS
MIDWEST ENT
“GET REAL”
WHAT IS CHRONIC RHINOSINUSITIS VS THE NORMAL “SNOTTY NOSE” KID?
MUST BALANCE THE SELF LIMITED NATURE OF THE DISEASE ITS SIGNIFICANT MORBITITY.
Rhinosinusitis
A GROUP OF DISORDERS CHARACTERIZED BY INFLAMMATION OF THE MUCOSA OF THE NOSE AND PARANASAL SINUSES
THERE IS NO CRITERIA BASED ON ETILOGY
RHINOSINUSITIS
REALLY AN IMFLAMMATORY DISORDER
NEED TO STOP THINKING OF IT AS SOLEY AN INFECTION (INFECTION IS REALLY THE RESULT)
Rhinosinusitis
Rhinosinusitis is the preferred terminology as you DON’T get the sinusitis without the rhinitis.The term is then further defined by the duration of the inflammationACUTE – LESS THAN 4 WEEKSRECURRENT ACUTECHRONIC-MORE THAN 12 WEEKS
FORM AND FUNCTION
FORM (ANATOMY) FUNCTION (PHYSIOLOGY)
ANATOMY (FORM)
DEVELOPING SINUSES
PHYSIOLOGY (FUNCTION)
NASAL PASSAGESBREATHING
WARMING
FILTERING
HUMIDIFYING
OLFACTION (SENSE OF SMELL)
RESISTANCE
SINUSESLIGHTEN THE SKULL
MUCOUS PRODUCTION
HUMIDIFICATION
PROTECT FROM FALCIAL TRAUMA
PROTECT NASAL BAROTRAUMA
VOCAL RESONANCE
ENHANCE OLFACTION
RHINOSINUSITIS---HOW DO YOU GET IT
INFLAMMATION---BLOCKING OF THE OSTIA—DIMINISHED PH---MUCOCILIARY DYSFUNCTION----STAGNATION OF SECRECTIONS---OVERGROWTH OF BACTERIA OR FUNGUS
RHINOSINUSITIS
INFLAMMATION CAUSED BY: ?
OMC: AREA OF RELATIVELY TIGHT ANATOMY
CAUSATIVE FACTORS:
URI’S---CHILDREN CAN GET 6-8-10 “COLDS” YEAR AND 5-10% CAN BE COMPLICATED BY ARS
CAUSATIVE FACTORS
BACTERIAL PATHOGENS:
BIOFILMS
SUPERANTIGENS (RELATIONSHIP WITH ATOPIC DERMATITIS)
HIGH MOLECULAR WEIGHT PYROGENIC PROTEINSELICIT EXTREMELY POTENT STIMULATORY EFFECT ON T-LYMPHOCYTES
SUPERANTIGENS
BACTERIA (staph aureus, pseudomas, H influenza)
FUNGI (Molds, Candida, Bipolaris, Alternaria, Aspergillosis)
Allergens (Conventional and Bacterial antigens)
Irritants
CAUSATIVE FACTORS
ALLERGIES: INHALANT AND INGESTANT---60-90% OF SURGICAL PTS HAVE SIGNIFICANT ALLERGIES ON SKIN TESTING
CAUSATIVE FACTORS
ADENOIDITIS---PHARYNGEAL TONSIL CAN OFTEN SERVE AS A BACTERIAL RESERVOIR
75% OF PEDIATRIC CRS IMPROVES WITH ADENOIDECTOMY (?TONSILLECTOMY)
CAUSATIVE FACTORS
AIRWAY POLLUTANTS: MOST PROMINENTLY SECOND HAND SMOKE
CAUSATIVE FACTORS
GERD: PROBABLY BY CAUSING ADENOIDITIS.
RECENT STUDY BY PARSONS SUGGESTED SIGNIFICANT CAUSATION.
CAUSATIVE FACTORS
STRUCTURAL ABNORMALITIES:DEVIATED SEPTUMMAXILLARY SINUS HYPOPLASIALATERAL WALL ANOMALIES (HALLER CELL, CONCHA BULLOSA, PARADOXICAL MIDDLE TURBINATE)
CAUSATIVE FACTORS
PRIMARY IMMUNO- DEFICIENCY (PID)TRANSIENT HYPOGAMMA GLOBULINEMIAIgG SUBCLASS DEFICIENCYOTHERS
CAUSATIVE FACTORS
PCD (PRIMARY CILIARY DYSKINESIA)---50% HAVE KARTAGENER’S SYNDROME
CAUSATIVE FACTORS
CYSTIC FIBROSIS-WITH NEWER GENETIC TESTING (CF MUTATION ANALYSIS) WE ARE ABLE TO DIAGNOSE MANY LESS SEVERE VARIANTS
RHINOSINUSITIS
HOW DO YOU DIAGNOSE IT?
HOW DO YOU TREAT IT?
DIAGNOSIS
HISTORY
PHYSICAL
ENDOSCOPY
CT SCAN
DIAGNOSIS
MAJOR FACTORS
FACIAL PAIN/PRESSURE
NAO
DISCHARGE
HYPOSMIA
PURULENCE
FEVER
MINOR FACTORS
HEADACHE
FEVER
HALITOSIS
FATIGUE
DENTAL PAIN
COUGH
AURAL PAIN/FULLNESS
MAXIMAL MEDICAL THERAPY
SALINE (SPRAY/IRRIGATIONS)—HYPERTONIC?
DECONGESTANTS (TOPICAL/SYSTEMIC)
MUCOLYTICS
STEROIDS (TOPICAL/SYSTEMIC)
ANTIHISTAMINES (TOPICAL/SYSTEMIC)
REFLUX THERAPY?
MAXIMAL MEDICAL
LEUKOTRIENE INHIBITORSANTIBIOTICS (TOPICAL/SYSTEMIC)USUALLY START TREATMENT
EMPIRICALLY---TREAT AT LEAST 1 WEEK PAST THE RESOLUTION OF SYMPTOMS (OFTEN 20 DAYS)
SINUNEB—IRRIGATIONSCHRONIC---LOW DOSE CHRONIC
BIAXIN
ALLERGY
THE NOSE IS THE TARGET ORGAN FOR AEROALLERGENS, IRRITANTS, AND DEBRIS.
TOPICAL THERAPIES AND NASAL RINSES ARE PARAMOUNT.
ALLERGY
ALLERGY TESTING AND TREATMENT IS NEVER A BAD IDEA PRIOR TO SURGERY
IDT IS THE MOST SENSITIVE AND SPECIFIC METHOD OF ALLERGY TESTING
SURGERY
THE CHRONIC INFLAMMATION FROM ALLERGIES AND INFECTIONS CAN LEAD TO ANATOMIC CHANGES SINONASAL INFECTION IS A RELATIVE TERMMOST MUCOSAL PROBLEMS ARE REVERSIBLESINUS SURGERY IS PLAN C
SINUS SURGERY
WE DO IT BETTER---UTILILIZE LASERS, ENDOSCOPES, TV MONITORS, MICRODEBIDERS, COMPUTER GUIDANCE SYSTEMS----STILL A DRAINAGE PROCEDURE
FUNCTIONAL
IMAGE GUIDED
LASER AND POWERED
MINIMALLY INVASIVE