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Chronic rhinosinusitis in children

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Chronic rhinosinusitis in children
Presented by Anchalee Senavonge, MD.
October7, 2016

Published in: Health & Medicine
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Chronic rhinosinusitis in children

  1. 1. Chronic rhinosinusitis in children Anchalee Senavonge MD. Pediatric Allergy and Immunology department Chulalongkorn University
  2. 2. Definition Middletion textbook 8th edition, European position paper 2012
  3. 3. Definition Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter Recurrent ARS: at least 3 episodes of ABRS in 1 yr
  4. 4. Phenotypes of CRS Ann Allergy Asthma Immunol 117 (2016)
  5. 5. Development of sinuses • Maxillary sinus-1st , begin pneumatization from birth to 12 mo • Ethmoid: present at birth, reach adult size 12-14 yr • Frontal and sphenoid: later, complete pneumatization at mid to late adolescence Diagnosis and management of rhinosinusitis: a practice parameter 2014
  6. 6. Diagnosis and management of rhinosinusitis: a practice parameter 2014 Ostiomeatal complex
  7. 7. Sinus physiology • Pseudostratified, ciliated columnar epithelia interspersed with globlet cells • Obstruction mucous impaction and ↓oxygenation ▫ limited gas exchange  ↓ oxygen concentrations anaerobic condition  bacteria growth ▫ ↓ Air pressure  causes pain and pressure sensation • Acute purulent sinusitis- ↑pressure pain due to inflammation of the mucosa and pressure from intra-sinus secretions • Role of biofilm: “mortar” composed of a bacterially extruded exo- polymeric matrix (protein and nucleic acid) Diagnosis and management of rhinosinusitis: a practice parameter 2014
  8. 8. Microbiology in CRS Adults • Aerobes: Streptococcus species (21%), H influenzae (16%), P aeruginosa (16%), S aureus (10%), and M catarrhalis (10%). • Anaerobes: Prevotella species (31%), Streptococci (22%), Fusobacterium(16%). Children • Alpha-hemolytic streptococcus (20.8%), H influenzae (19.5%), S pneumoniae (14.0%), S epidermidis (13.0%), and S aureus (9.3%). • Anaerobes were recovered from 8.0% of all isolates Bacteriologic findings associated with chronic bacterial maxillary sinusitis in adults. Clin Infect Dis. 2002 Maxillary sinus puncture with endoscopic middle meatal culture in pediatric rhinosinusitis.Am J Rhinol. 2008
  9. 9. Microbiology in CRS Nosocomial rhinosinusitis • gram-negative enteric species (eg, P aeruginosa, Klebsiella pneumoniae, Enterobacter species, Proteus mirabilis, and Serratia marcescens) • gram-positive cocci (occasionally streptococci and staphylococci) CRSwNP • Polymicrobial aerobic and anaerobic flora Bacteriology of chronic maxillary sinusitis associated with nasal polyposis. J Med Microbiol. 2005 Nosocomial sinusitis: a unique subset of sinusitis. Curr Opin Infect Dis. 2005;
  10. 10. Clinical manifestation
  11. 11. History • Persistent cough, prolonged anterior and posterior nasal drainage, congestion • low-grade fever, irritability, and behavioral difficulties • Headache, especially in the frontal area, is a less common • Frequent URI or recurrent sinusitis • Additional history should focus on identification of any potential contributing factors CRS in children. Pediatr Clin N Am 2013
  12. 12. Physical examination CRS in children. Pediatr Clin N Am 2013
  13. 13. Approach to CRS
  14. 14. Diagnosis and management of rhinosinusitis: a practice parameter 2014
  15. 15. Diagnosis and management of rhinosinusitis: a practice parameter 2014
  16. 16. Medical treatment of pediatric chronic rhinosinusitis. Am J Rhinol Allergy 2016
  17. 17. Stepwise evaluation of CRS CRS Epidemiology and medical management. JACI 2011
  18. 18. Contributing factors in CRS CRS in children. Pediatr Clin N Am 2013
  19. 19. Approach to CRS CRSsNP CRSwNP • Anatomical defect/ variation • Trauma, foreign body • Environmental triggers • Allergy • Immunodeficiency • GERD • Eosinophilic mucin RS (EMRS) • Aspirin intolerance • Allergic fungal RS (AFRS) • Cystic fibrosis • Primary ciliary dyskinesia
  20. 20. Structure defect • Septal deviation, Haller cells, paradoxical curvature of the middle turbinate, and agger nasi cells ▫ predispose to obstruction of the ostiomeatal unit, development of CRS, or both CRS Epidemiology and medical management. JACI 2011
  21. 21. Environmental triggers • Pollution: carbon monoxide, nitrous dioxide, sulfur dioxide • Irritants in air pollution: sulfur dioxide ozone and formaldehyde (indoor pollutant) • Hay fever • Indoor dampness and mold exposure • Active and secondhand cigarette smoking CRS Epidemiology and medical management. JACI 2011
  22. 22. Allergic/ nonallergic rhinitis • Congestion interfere drainage, ↑secretionhypoxic and acidosis leads to mucociliary dysfunction bacteria multiply • CRS 36-60% have AR children, 40-84% in adult • CRS with AR likely to have persistent disease despite FESS • Test: SPT, specific IgE Diagnosis and management of rhinosinusitis: a practice parameter 2014
  23. 23. Sinusitis-asthma • การสูดสารคัดหลั่งจากไซนัสลงไปในปอด • การกระตุ้นผ่านประสาทสมองคู่ที่ 10 เกิดreflex bronchospasm • การหายใจทางปากทาให้เกิดภาวะหลอดลมแห้งและกระตุ้นการ สร้างสารที่มีฤทธิ์ ทาให้หลอดลมตีบโดยตรง • การกระตุ้นผ่านทางเซลล์ชนิดต่างๆ ที่เกี่ยวกับการอักเสบ เช่น ทาให้ eosinophils เข้าไปในเยื่อบุของทางเดินหายใจทั้งในไซนัสและหลอดลมมาก ขึ้น เอกสารประกอบการประชุมวิชาการประจา 2559 สมาคมสภาองค์กรโรคหืดแห่งประเทศไทย
  24. 24. เอกสารประกอบการประชุมวิชาการประจา 2559 สมาคมสภาองค์กรโรคหืดแห่งประเทศไทย
  25. 25. Immunodeficiency • “Humoral” • Other: ▫ Ataxia telangiectasia, WAS, C3 deficiency Immunodeficiency in chronic sinusitis. Am J Rhinol Allergy 2015 Infectious CRS, JACI 2016
  26. 26. Immunodeficiency • Test ▫ IgA, IgM, IgG, specific Ab level to polysaccharide vaccine and tetanus/Diphtheria, flow cytometry, level of complement ▫ IgG subclass not typically recommended Immunodeficiency in chronic sinusitis. Am J Rhinol Allergy 2015
  27. 27. Immunoglobulin deficiency in patients with CRS: Systematic review of the literature and meta-analysis. JACI2015 Immunodeficiency-Systematic review
  28. 28. Immunodeficiency CRS in children • Shapiro et al • 34 of 61 children with refractory sinusitis • decreased IgG3 levels and poor response to pneumococcal antigen -most common CRS Epidemiology and medical management. JACI 2011
  29. 29. • 94 children with RARS • Mean age 7.7+_2.6 yr • 6 patients not respond to other therapy --> received IVIg, 4/6 responded Clinical characteristics of recurrent acute rhinosinusitis in children. Asian Pac J Allergy Immunol 2015 Immunodeficiency-Siriraj study
  30. 30. CRSwNP Middletion textbook 8th edition
  31. 31. • Eosinophils staining positive for the anti–eosinophil cationic protein (ECP) antibody EG2: prominent and characteristic finding 80% of polyps • Lymphocytes and neutrophils: predominant in CF and PCD Ann Allergy Asthma Immunol 117 (2016) CRSwNP
  32. 32. Allergic fungal rhinosinusitis (AFRS) • CRSwNP with characteristic eosinophilic mucin • semisolid nasal crusts that are similar to allergic mucin-peanut butter like • presence of fungi in the mucin by staining or culture • Most common: Bipolaris, Curvalaria, Aspergillus, Drechslera species Diagnosis and management of rhinosinusitis: a practice parameter 2014 CRS Epidemiology and medical management. JACI 2011
  33. 33. AFRS 1. Opacified sinus cavities despite extensive medical therapy 2. Characteristic CT hyperdensities within the opacified sinuses, which suggest accumulated allergic mucin 3. Evidence of IgE-mediated allergy CT scans : opacified nasal cavities and paranasal sinuses ‘‘hyperdensities'' within the opacified sinuses, as well as local and linear areas of increased density within the nasal cavities. CRS Epidemiology and medical management. JACI 2011
  34. 34. AFRS
  35. 35. Cystic fibrosis • Mutations in CFTR on chromosome 7 • ↓Chloride ion secretion result in ▫ ↑secretion viscosity ▫ also -dilation of glandular ducts,↑ submucosal gland,↑ surfactant gene expression • Suspect when ▫ CRS in young ages (< 6 yr)with nasal polyps (40%) ▫ Pseudomonas aeruginosa, Burholderia capacia colonization ▫ chronic lung infection, pancreatic insufficiency • Test: Gibson-Cooke sweat test or quantitative pilocarpine iontophoresis DNA analysis Medical treatment of pediatric chronic rhinosinusitis. Am J Rhinol Allergy 2016 Diagnosis and management of rhinosinusitis: a practice parameter 2014
  36. 36. Ciliary dysfunction • Primary ciliary dyskinesia (Kartagener syndrome) • rare AR disorder 10 per million • Suspect when ▫ recurrent otitis media, CRS, pneumonia wih bronchiectasis ▫ situs inversus, sterile • Test: screen-nasal nitric oxide (low in PCD) and the saccharine test, definite-transmission electron microscopy Diagnosis and management of rhinosinusitis: a practice parameter 2014
  37. 37. CRSwNP Clinical clues Eosinophilic mucin RS • eosinophilic mucin, co-morbid asthma • CT opacity AERD • multiple polyps, rapid growth • Samter triad • universal recurrence after surgery AFRS • often unilateral/limited to 1 or a few sinus cavities • eosinophilic mucin with fungal hyphae and fungal allergy • CT opacity, hyperdensities and bony erosion CF • <6yr • neutrophilia suggesting the high prevalence of acute superinfections • Pseudomonas aeruginosa or Burkholderia cepacia • chronic lung infections or pancreatic insufficiency Kartagener syndrome Neutrophil, sinus inversus, recurrent otitis media, bronchiectasis
  38. 38. Management of CRS
  39. 39. Medical treatment of pediatric chronic rhinosinusitis. Am J Rhinol Allergy 2016
  40. 40. Medical treatment of pediatric chronic rhinosinusitis. Am J Rhinol Allergy 2016
  41. 41. Management in CRS • Medical ▫ Systemic antibiotic ▫ Glucocorticoids ▫ Combination systemic antibiotics and steroid ▫ Topical steroid irrigations ▫ Saline irrigations ▫ Antihistamines ▫ Leukotriene modifiers ▫ Antifungal drugs • Surgical ▫ Adenoidectomy ▫ FESS ▫ Maxillary antral irrigation ▫ Balloon sinuplasty
  42. 42. Systemic antibiotics • Controversial- lack of evidence • should use for acute exacerbation • First-line: broad spectum such as Amoxicillin-clavulanic acid • If MRSA suspected: combine Clindamycin, TMP-SMZ • Cystic fibrosis: Fluoroquinone (cover Pseudomonas) • Macrolide: anti-inflammatory effect CRS in children: what a the treatment options? Immunol Allergy Clin N Am 2009 CRS : epidermiology and medical management. JACI 2011
  43. 43. Systemic antibiotics CRSsNP • Short-term (<4 wk) ▫ cefaclor/amoxicillin improve in RARS (56%) ▫ Amoxicillin-clavulanic 67% vs ciprofloxacin 83% (cure rate, 9 days) • Prolong course ▫ Open label adult study- clindamycin/amox-clav/ doxycycline 6 wk: improve CT at 3, 6 wk CRSwNP • S aureus colonization 64% ▫ Doxycycline for 20 days – smaller polyps, secretion ▫ Doxycycline –small effect on size at 12 wk (quinolone, amox-clav not) Oral steroids and doxycycline: approaches to treat nasal polyps. JACI 2010 Short-term ATB in nasal polyps and S aureus. Eur Arch Otorhinolaryngol2009 Cefaclor vs amoxicillin in the treatment of sinusitis. Arch Fam Med. 1993 Radiographic resolution of CRS after oral antibiotics. Ann AlAsthma Imm2007
  44. 44. Long term systemic Macrolide • Anti inflammatory effect in addition to bacteriostatic • Erythromycin 500 mg/d 2 wk then 250 mg/d 10 wk combine with nasal irrigation and INCS – improve • Roxithromycin 150mg/d 12 wk – change from baseline at 12 wk • Azithromycin 500 mg/d 3 d then 200mg/wk 11 wk - no significant Evaluation of the medical and surgical treatment of CRS . Laryngoscope. 2004. A dbRCT of macrolide in the treatment of CRS. Laryngoscope. 2006 Lack of efficacy of long-term, low-dose azithromycin in CRS. Allergy 2011
  45. 45. Systemic antibiotics in children • Available data does not justify the use of short-term oral antibiotics for the treatment of CRS in children (Strength of recommendation: B) • There might a place for longer-term antibiotics (equivalent to CRS in adults) (Strength of recommendation: D) • Combination ATB+INCS, no specific recommendation for duration • Short-term show inadequate to relieve symptoms, long –term 3-6 weeks most recommend European position paper on Rhinosinusitis and nasal polyp 2012 CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009
  46. 46. Systemic antibiotics in children • Lack of good evidence, often treat with same ATB for ARS • Type often depends on local resistance patterns • IV antibiotics- lack of RCT, other intenvention ▫ Retrospective study (Don et al) -89% resolution after maxillary sinus irrigation and adenoidectomy followed by IV ATB 1-4 wk (Cefuroxime>Sulbactam>Ticarcillin clavulanate>Vancomycin) Diagnosis and management of Rhinosinusitis, a practice parameter update.2014
  47. 47. Topical antibiotics • Systematic review -antibiotic nasal irrigations or nebulizations • Both CRS and acute exacerbations of CRS might benefit • Use 3 to 6 weeks • Topical irrigation with 80 mg/L gentamicin or tobramycin can also be useful • Caution: SNHL 23% in CF +frequent irrigations with aminoglycosides Topical antimicrobials in the management of CRS: a systematic review. Am J Rhinol 2008 CRS : epidermiology and medical management. JACI 2011
  48. 48. Intranasal steroids • Helpful in all types of CRS • no RCT in children, recent study show modest benefit • suppress mucosal inflammation especially co-morbid with AR, asthma • CRS can exacerbate asthma INCS reduce • duration coincide with the longer use of antibiotics typically 3-6 wk • Mometasone fuorate 2 yr, Fluticasone propionate 4 yr CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009 CRS in children. Pediatr Clin N Am 2013
  49. 49. Systemic steroid • A brief course of oral glucocorticoids - treatment for NP (‘medical polypectomy'), AFRS • Children ▫ additional effect on cough, CT scan, nasal obstruction ▫ consider when INCS fail to relieve mucosal inflammation • Hamilos. JACI 2011 ▫ prednisone 20 mg bid x 5 d10 mg bid x5 d 10 mg od x 5 d TCS • British guidelines ▫ prednisolone 0.5 mg/kg for 5-10 days + betamethasone nasal drops • Hissaria, JACI2006(Adult trial) ▫ prednisone 30 mg od x 4 d with 5 mg↓ q2days IN budesonide 400 mg bid CRS Epidemiology and medical management. JACI 2011 CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009
  50. 50. Systemic steroid in children • No RCT in children • Amoxicillin/clavulanate for 30 days and randomized to receive methylprednisolone or placebo, average age 8 yr ▫ 1 Mkday for 10 days, 0.75 MKday for 2 days, 0.5 MKday for 2 days, 0.25 MKday for 1 day • CT score +symptom - significant improvements both ATB alone and ATB+ steroids Efficacy and tolerability of systemic methylprednisolone in children and adolescents with CRS: dbRCT. JACI2011
  51. 51. Topical steroid irrigations • Aqueous budesonide 5-mg respule + 1 tsp of saline- benefit in CRS ▫ head down forward-->right lateral supine-->supine position, 1-2 min once daily • Fluticasone propionate 200 mg per nostril - benefit in polyp ▫ Position: lie on backs with heads hanging down in an inverted vertical position, 2 min, once daily • reduced the need for surgery, improved hyposmia, and decreased nasal polyp volume CRS : epidermiology and medical management. JACI 2011
  52. 52. • Objective=evaluate the efficacy of postoperative topical sinonasal steroid irrigations for CRS ▫ budesonide (1 mg) or betamethasone (1 mg) in 240 mL of normal saline solution • Improve SNOT-22 score, esp high tissue eosinophilia (>10/hpf)
  53. 53. Nasal saline and nasal spray • Adjunctive • saline irrigation and sprays (1-4 times/day) -effective • less effective as monotherapy compared to topical steroid • Effect: reduces postnasal drainage, removes secretions, rinses away allergens and irritants, and improves mucociliary clearance • Nasal larvage (at least 200 mL of warmed saline) with squeeze bottles, syringes, and pot Nasal saline irrigations for the symp-toms of chronic rhinosinusitis. Cochrane Database Syst Rev 2007
  54. 54. Adjunctive therapy • Antihistamine • Decongestant • Mucolytic agents • Antileukotriene ▫ Adjunct to topical glucocorticoids in the treatment of CRSwNP ▫ more effective in those with concomitant asthma and aspirin intolerance (AERD) • Antireflux therapy CRS Epidemiology and medical management. JACI 2011 CRS in children. Pediatr Clin N Am 2013
  55. 55. Antifungal • Based on "fungal hypothesis" • Studies showed (1) fungal hyphae colonize in patients with CRS (2) CRS show a systemic immune hyperresponsiveness to common inhalant fungi, such as Alternaria species • However, neither topical antifungals (sprays and irrigations) nor systemic terbinafine are beneficial Diagnosis and management of Rhinosinusitis, a practice parameter update.2014 CRS Epidemiology and medical management. JACI 2011
  56. 56. CRS Epidemiology and medical management. JACI 2011
  57. 57. CRSsNP • Intensive medical therapy: a brief course of systemic glucocorticoids + a prolonged course of oral antibiotics + 1 or more adjunctive therapies • Typical regimen: oral prednisone 20 mg bid for 5 days 20 mg od for 5 days plus 3 -4 weeks of oral ATB (Amoxicillin-clavulanate is an excellent choice for most), sinus culture • extend up to 6 weeks in patients with colored secretion • Maintenance: TCS, considers long-term macrolide CRS Epidemiology and medical management. JACI 2011
  58. 58. CRS Epidemiology and medical management. JACI 2011
  59. 59. CRSwNP -management • Initial: brief course of oral glucocorticoids, TCS • Maintenance: ▫ TCS ▫ Mucosal colonization with S aureus 64% CRSwNP (30% healthy) –Doxycycline begin at week 2 and persist for 12 weeks ▫ Antileukotrienes and aspirin desensitization ▫ Surgery CRS Epidemiology and medical management. JACI 2011
  60. 60. CRS Epidemiology and medical management. JACI 2011
  61. 61. AFRS- management • Surgery • Systemic steroid: 1 mg/kg prednisone for 10 days, slowly reduced by 1 to 2.5 mg/wk post-op • after surgery, topical glucocorticoid with budesonide • oral or topical antifungal- no trials, some respond (200 mg twice- daily oral itraconazole to adults for 3 to 6 months) CRS Epidemiology and medical management. JACI 2011
  62. 62. Indication for surgery in CRS 1. Complete nasal obstruction in CF caused by massive polyposis or medialization of the lateral nasal wall 2. Orbital abscess 3. Intracranial complications 4. Antrochoanal polyp 5. Mucocoeles or mucopyocoeles 6. Fungal rhinosinusitis CRS Epidemiology and medical management. JACI 2011
  63. 63. Adenoidectomy • Remove infection reservoir, biofilms • Meta-analysis in children 9 studies, mean age 5.8 yr-8/9 show improvement 69.3% • One study (Ramadan) show asthma +young(<7yr) likely to fail combine with FESS CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009 Diagnosis and management of Rhinosinusitis, a practice parameter update.2014
  64. 64. Maxillary antral irrigation • Optimize benefit of adenoidectomy • Clear seceretion/infection+ provide culture material • Adenoidectomy alone 61% vs combine 88% (in 32 children with CRS) • Post-op antibiotic- no improvement, not necessary Diagnosis and management of Rhinosinusitis, a practice parameter update.2014 CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009
  65. 65. Functional endoscopic sinus surgery (FESS) • When adenoidectomy fail-stepwise approach • Mucociliary clearance disorder such as CF, Kartagener syndrome- offer first option • In children, less widespread due to concerns of hindering midface growth • Outcomes are excellent 80-100% improve • Second-look: majority not endorsed • Risk (meta-analysis -0.6%) globe, CSF leak, nasolacrimal duct injury CRS in children: what are the treatment option. Imm Allergy Clin N Am 2009
  66. 66. • Many advocate a conservative approach to FESS in children, limited to removal of any obvious obstruction (such as polyps and concha bullosa), as well as anterior bulla ethmoidectomy and maxillary antrostomy
  67. 67. Balloon catheter sinuplasty (BCS) • Ballon dilatation of sinus ostia • Alternative to FESS • primarily used for maxillary sinus CRS in children. Pediatr Clin N Am 2013
  68. 68. Thank you

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