دانشجویان پزشکی 87 کرمان
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• Acute sinusitis: infection lasting ,4 wk, with complete resolution of symptoms.
• Subacute infection: lasts from 4 to 12 wk, with complete resolution of symptoms.
• Recurrent acute infection: episodes of acute infection lasting ,30 days, with resolution of symptoms, which recur at intervals at least 10 days apart.
• Chronic sinusitis: inflammation lasting .12 wk, with persistent upper respiratory symptoms.Acute bacterial sinusitis superimposed on chronic sinusitis new symptoms that occur in patients with residual symptoms from prior infection(s). With treatment, the new symptoms resolve but the residual ones do not.
PHYSICAL FINDINGS & CLINICAL
• Patients often give a history of a recent upper respiratory illness with some improvement,then a relapse.
• Mucopurulent secretions in the nasal passage:
1. Purulent nasal and postnasal discharge lasting 7 to 10 days
2. Facial tightness, pressure, or pain
3. Nasal obstruction
5. Decreased sense of smell
6. Purulent pharyngeal secretions, brought up with cough, often worse at night
• Erythema, swelling, and tenderness over the infected sinus in a small proportion of pa-tients:
1. Diagnosis cannot be excluded by the ab-sence of such findings.
2. These findings are not common, and do not correlate with number of positive si-nus aspirates.
• Intermittent low-grade fever in about half of adults with acute bacterial sinusitis.
• Toothache is a common complaint when the maxillary sinus is involved.
• Periorbital cellulitis and excessive tearing with ethmoid sinusitis:
1. Orbital extension of infection: chemosis, proptosis, impaired extraocular movements
• Characteristics of acute sinusitis in children with upper respiratory tract infections:
1. Persistence of symptoms
3. Bad breath
• Symptoms of chronic sinusitis (may or may not be present):
1. Nasal or postnasal discharge
3. Facial pain or pressure
• Nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation.
• The diagnosis is generally based on clinical signs and symptoms (purulent rhinorrhea and facial pain). Radiologic tests and cultures are not recommended initially and should be considered only when treatment is ineffective and sinusitis persists.
• Gold standard for diagnosis: recovery of bacteria in high density colony-forming units/ml from a paranasal sinus, in the setting of a patient with history of upper respiratory infection and symptoms persisting for 7 to 10 days.
1. Standard four-view sinus radiographs
a. Complete opacification and air-fluid levels are most specific findings (aver-age 85% and 80%, respectively)
b. Mucosal thickening has low specificity (40% to 50%)
c. Absence of all three of the previous findings has estimated sensitivity of 90%
d. Overall, standard radiographs are of limited use in diagnosis, although negative films are strong evidence against the diagnosis
2. CT scans:
a. Much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses
b. Recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to guide therapy
a. Used for diagnosis of frontal and max-illary sinusitis
b. Place transilluminator in the mouth or against cheek to assess maxillary si-nuses, under medial aspect of the supraorbital ridge to assess frontal sinuses
c. Absence of light transmission indicates that sinus is filled with fluid
d. Dullness (decreased light transmission) is less helpful in diagnosing infection
a. Used to visualize secretions coming from the ostia of infected sinuses
b. Culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture
5. Sinus puncture:
a. Gold standard for collecting sinus cultures
b. Generally reserved for treatment failures, suspected intracranial extension, and nosocomial sinusitis
To help promote sinus drainage:
• Air humidification with vaporizers (for steam) or humidifiers (for a cool mist)
• Application of hot, wet towel over the face
• Sipping hot beverages
ACUTE GENERAL Rx
• Sinus drainage:
1. Nasal vasoconstrictors, such as phenyl-ephrine nose drops, 0.25% or 0.5%
2. Topical decongestants should not be used for more than a few days because of the risk of rebound congestion
3. Systemic decongestants
4. Nasal or systemic corticosteroids, such as nasal beclomethasone, short course oral prednisone
5. Nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood flow)
6. Use of antihistamines has no proven benefit, and the drying effect on the mucous membranes may cause crusting, which blocks the ostia, thus interfering with si-nus drainage
• Analgesics, antipyretics
• Most cases of acute sinusitis have a viral cause and will resolve within 2 wk without antibiotics.
• Current treatment recommendations favor symptomatic treatment for those with mild symptoms. Physicians grossly overprescribe antibiotics for presumed bacterial sinusitis despite a much higher prevalence of viral infections.
• Antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of sinusitis.
• Antibiotic therapy is usually empiric, targeting the common pathogens:
1. First-line antibiotics include amoxicillin,erythromycin, TMP-SMX.
2. Second-line antibiotics include the newer macrolides: clarithromycin, azithromycin, amoxicillin/clavulanate, cefuroxime axetil, cefprozil, cefaclor, loracarbef, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, metronidazole, and others.
3. For patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the costlier second-line agents.
• Hospitalization and IV antibiotics may be required for more severe infection and those with suspected intracranial complications. Broader-spectrum antibiotic coverage maybe indicated in severe cases, to cover for MRSA, Pseudomonas, and fungal pathogens.
• Duration of therapy generally 10 to 14 days,
although some have success with much shorter regimens.
• Surgical drainage indicated
1. If intracranial or orbital complications suspected
2. Many cases of frontal and sphenoid sinusitis
3. Chronic sinusitis recalcitrant to medical therapy
• Surgical debridement imperative in the treat-ment of fungal sinusitis
• Broad-spectrum antibiotics that cover both aerobes and anaerobes
• Duration of therapy not clearly established: range 3 to 6 wk
• Adjunctive therapy: one or more of the various options listed previously
• Surgical intervention may be necessary in Nonresponders
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