Date post: | 14-Apr-2018 |
Category: |
Documents |
Upload: | mike-sihombing |
View: | 223 times |
Download: | 0 times |
of 34
7/27/2019 EENT Update for Primary Care
1/34
Sinusitis and Otitis Media for
Primary Care Providers
DeWitt Army Community Hospital
Fort Belvoir, VA
DeWitt Health Care Network
Alicia R. Sanderson, MDLCDR, MC, USN
Otolaryngology-Head and Neck SurgeryFacial Plastics & Reconstructive Surgery
7/27/2019 EENT Update for Primary Care
2/34
Sinusitis-Objectives
Define Adult Rhinosinusitis and subtypes Review evidence based medicine
Suggest a treatment algorithm
Review appropriate antibiotic selection and
adjuvant therapies
7/27/2019 EENT Update for Primary Care
3/34
Definitions
Rhinosinusitis- symptomatic inflammation ofthe paranasal sinuses and nasal cavity
Uncomplicated Rhinosinusitis- without
clinically evident extension of inflammationoutside the paranasal sinuses and nasal cavity (no
neurologic, opthalmologic or soft tissue
involvement)
Acute (12 weeks)
7/27/2019 EENT Update for Primary Care
4/34
Diagnosis-Acute
Up to 4 weeks ofpurulent nasal discharge
with nasal obstruction and/or facial pain
pressure
ABRS vs VRS
ABRS when sxs are present for10 days or
more OR symptoms worsen within 10 daysafter initial improvement (double worsening)*
*Purulent discharge can occur in viral or bacterial infections
7/27/2019 EENT Update for Primary Care
5/34
Evaluation-Acute
Imaging isNOT recommended in
uncomplicated acute rhinosinusitis
7/27/2019 EENT Update for Primary Care
6/34
Treatment-Acute Symptomatic relief of VRS
analgesics/antipyreticsTopical or systemic decongestants
NO benefit systemic steroids or antihistamines
Symptomatic relief of ABRSAnalgesics
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
7/27/2019 EENT Update for Primary Care
7/34
Treatment-Acute
Watchful Waiting of ABRSobserve without Abx up to 7 days afterdiagnosis
Uncomplicated, mild illness (temp
7/27/2019 EENT Update for Primary Care
8/34
Treatment-Acute
Antibiotic use for ABRSStrep pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis
First line therapy: Amoxicillin or trimethoprim-
sulfamethoxazole 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 narrowspectrum
Common duration 10 days
7/27/2019 EENT Update for Primary Care
9/34
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
7/27/2019 EENT Update for Primary Care
10/34
Sinusitis
Antimicrobial EfficacyTherapy Clinical efficacyAmoxicillin/clavulanate 90-91%
Amoxicillin 87-88%
Cefpodoxime 87%
TMP/SMX 83%
Doxycycline 81%
Azithromycin 77%
Gatifloxacin/levofloxacin 92%
Clindamycin 92%
Antimicrobial Treatment Guidelines for ABR 2004, Otolaryngology-HN Surgery, January 2004
7/27/2019 EENT Update for Primary Care
11/34
Diagnosis-Chronic
Nasal obstruction, facial congestion-
pressure, decreased sense of smell, purulent
discharge for >12 weeks AND documentedinflammation (edema, polyps, radiographic
imaging)
Recurrent Acute- Four or more episodes inone year with symptom free intervening
periods
7/27/2019 EENT Update for Primary Care
12/34
Rhinology-Exam
Exam Polyps
Septal deviation/spurs
Rhinorrhea
Assess air flow
Polyps Polypoid changes
Septal spur
7/27/2019 EENT Update for Primary Care
13/34
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 40-
84% patients with CRS)
7/27/2019 EENT Update for Primary Care
14/34
Comorbid factors-Chronic
Allergic rhinitis, cystic fibrosis,
immunocompromised state (IgA, IgG, IgM,
HIV), ciliary dyskinesia and anatomicvariation
7/27/2019 EENT Update for Primary Care
15/34
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
7/27/2019 EENT Update for Primary Care
16/34
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 Surg2004;130(1Suppl 1):S1-45.
7/27/2019 EENT Update for Primary Care
17/34
Treatment-Chronic Adjuvant therapies
Smoking cessation
Saline irrigations
Nasal steroids
Short course systemic steroids (two weeks)
Surgical Intervention
7/27/2019 EENT Update for Primary Care
18/34
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 timeand treatment or if suspected complication
Consider modifying factors
7/27/2019 EENT Update for Primary Care
19/34
Otitis Media
Define otitis media and subtypes
Discuss natural course of disease
Treatment recommendations and indications
for surgical intervention
7/27/2019 EENT Update for Primary Care
20/34
Otitis Media-definitions
Acute Otitis (AOM)
Recurrent Acute Otitis (RAOM)
Chronic otitis (COM)
Otitis Media with Effusion (OME)
7/27/2019 EENT Update for Primary Care
21/34
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 TMmobility, air-fluid level in ME, Otorrhea
OME
Presence of MEE
7/27/2019 EENT Update for Primary Care
22/34
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)
Serous effusionAcute Otitis media
7/27/2019 EENT Update for Primary Care
23/34
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
7/27/2019 EENT Update for Primary Care
24/34
Acute Otitis Media Observation
Age Certain
Diagnosis
Uncertain
Diagnosis
2y Antibacterial therapy
if severe, observe if
not severe
Observation option
7/27/2019 EENT Update for Primary Care
25/34
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
7/27/2019 EENT Update for Primary Care
26/34
Otitis Media-Bacteria
Streptococcus pneumoniae, Haemophilusinfluenzae, Moraxella catarrhalis
Treatment
High dose Amoxicillin (80-90 mg/kg/day) first lineHigh 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 5-7 days (weak evidence)
7/27/2019 EENT Update for Primary Care
27/34
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
7/27/2019 EENT Update for Primary Care
28/34
Recurrent Acute Otitis Media
Reduce risk factorsAvoid 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 monthsComplications
Decrease rate of AOM 1 episode/child/yr or RR
reduction 56%
7/27/2019 EENT Update for Primary Care
29/34
Otitis Media with Effusion
Diagnosis with pneumatic otoscopy,
tympanometry
Document laterality, duration of effusion andseverity of sxs
Determine if child at risk for speech/learning
difficulty and evaluate hearing, speechPermanent hearing loss, language delay, autism,
syndromes, visual impairment, cleft palate
7/27/2019 EENT Update for Primary Care
30/34
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)
7/27/2019 EENT Update for Primary Care
31/34
Otitis Media with Effusion
No benefit to the use of antihistamines and
decongestants
Antimicrobials and steroids do not have longterm efficacy
7/27/2019 EENT Update for Primary Care
32/34
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 in6 months or more than ~4-5 episodes in 12 months
Chronic retraction of the tympanic membrane
7/27/2019 EENT Update for Primary Care
33/34
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
7/27/2019 EENT Update for Primary Care
34/34
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:S1-
32
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