Sinusitis, paranasal sinuses, viral or bacterial causes of allergic inflammation is defined as. Sinusitis affects the inflammation because the nasal mucosa "rhinosinusitis term" acute bacterial sinusitis (ABS) is better defined. Daytime cough, runny nose and nasal congestion symptoms such as the 10 days long, and 30 the day before in case of loss ABS, 4-12 weeks rode in case that a subacute bacterial sinusitis, 90 days or longer if chronic sinusitis is mentioned. At least a 10-day period ranges from asymptomatic recurrent ABS, recurrent acute bacterial sinusitis is called. When the ABS developed on the basis of chronic sinusitis, sinus symptoms who have acute sinusitis new symptoms during the acute episode is added, new symptoms disappear after antibiotic treatment, the symptoms of chronic sinusitis continues.
Viral upper respiratory tract infection (URTI), allergic rhinitis and sinusitis, accounted for the majority of patients seen in outpatient pediatric and three of these diseases, nasal congestion, runny nose and cough symptoms and gives. Allergic rhinitis, sinusitis and viral upper respiratory tract infections are the most important diseases that facilitate. 80% of bacterial sinusitis, viral sinusitis, allergic rhinitis, 20% play a facilitating role. Children 6-8 years of viral upper respiratory tract infection (URTI) spend. ABS 5-10% develop complications thereof. The natural course of uncomplicated viral upper respiratory tract infections has been well described. Fever, malaise, myalgia, sore throat, sneezing symptoms such as 3-8 days are lost; cough, runny nose and nasal congestion symptoms such as frequent in 25% of patients until day 14, day 14, more than 10% longer. The color and consistency of runny nose, sinusitis is viral or bacterial doesn distinguish. ABS diagnosis, the symptoms of upper respiratory tract infections 10-14. can be continued after the day on. Ongoing findings are generally in the form of daytime cough, and runny nose. Runny nose can be any color or consistency.
AGENTS AND FORMING MECHANISM
3-4 of pregnancy. developing maxillary and ethmoid sinuses in is present at birth. Maxillary sinus medial wall of the sinus outflow tract is found in the high gravity depends on the drainage of the sinuses. Ethmoid air cells, each of which consists of many an air cell, easily capable of clogging the middle meatus opens with a narrow ostium. Developed from a frontal sinus anterior ethmoid cells migrate on orbit in 5-8 years. Pituitary pit in front of the sphenoid sinus, posterior ethmoid is located behind, is usually 5 years off. Pansinüzit mostly as a component of the sphenoid sinus to become infected. Osteomeatal complex, between the middle and inferior meatus, frontal, ethmoid and maxillary sinus is where the confluence of the discharge region. Cilia movement is towards the opposite direction mucus retention occurring in this region predispose to infection.
Sinus ostia patency of the ciliary apparatus and secretion of normal function of the quality of the paranasal sinuses are the most important factors for normal physiology. Retention of mucus in the sinuses causing situations, sinus ostia obstruction, the number or function of cilia and secretory changes in the viscosity of the loss is acute, acute recurrent or chronic sinusitis causes. Mucosal edema, or mechanical obstruction of the cause of the obstruction results in sinus ostium. Ostial obstruction viral rhinosinusitis and allergic inflammation are the most common conditions that cause. When completely blocked sinus ostium temporary increase in pressure in the sinus is followed by the formation of negative pressure. Sinus ostium is opened again as a result of this negative pressure with sterile sinus cavity bacteria that colonize the nasopharynx flora of respiratory secretions can be reabsorbed. Sneezing, sniffling and sneezing, nasal, by increasing the inner pressure of the bacteria from the nasal cavity back facilitates entry sinus. The movement of cilia and mucus covering the respiratory epithelium of the adhesion of bacteria to protect from invasion. The number of cilia, changes in the structure and function facilitates entry of bacteria into the sinuses. Mucus like cystic fibrosis and asthma where darkening of consistency only movable when fluid mucus functions of cilia is disturbed. Found in the infected sinus cilia movement also prevents purulent material. Mucus stasis, hypoxia, micro-products and decreased mucociliary activity in chronic inflammation causes chronic sinusitis olurlar.b time to return to normal activity in most cases is longer than the duration of antibiotic therapy. Mucociliary activity, delayed healing, medical or surgical treatment is one of the causes of post-rekürrans. Another reason of Rekürrans bones that form the walls of the sinus is osteitis. Immotile cilia syndrome, cystic fibrosis and decreased disease activity in mucociliary mucociliary clearance is impaired. Antibody production in disorders (selective IgA deficiency, IgG production disorders, the usual variable hypogammaglobulinemia, and more rarely, selective IgG subclass deficiencies) recurrent sinus, there is a tendency to middle ear and lung infections. The incidence of acute sinusitis in patients with HIV infection is high.
Chronic sinusitis plays an important role in the pathogenesis of allergic inflammation. Impaired function of the mucosal epithelium plays an important role in the pathogenesis of sinusitis. Not only changes in epithelial hyperplasia, but also play a role in inflammation of epithelial cells depends on the composition of the product. Epithelial cells, IL-8, IL-6, IL-11, RANTES, MCP-1 and GM-CSF are responsible for the production of several cytokines such as. Furthermore, disruption of epithelial function and nitric oxide production in the sinuses, which help protect antbibakteriyel will decrease. These disorders in epithelial function facilitates colonization of bacteria in the sinus. Several bacterial products epithelial function and inflammation by affecting cytokine production increases. Long-term continuation of inflammation and thickening of the epithelial cells leads to goblet cell hyperplasia. Rhinovirus, respiratory syncytial virus and influenza virus infection induced the production of various cytokines. IL-8, neutrophils and some T-lymphocytes to cause accumulation of sinus mucosa, RANTES is chemotactic for eosinophils. GM-CSF collected in the sinus mucosa will extend the life span of neozinofil. When activated eosinophils in epithelial cells with secretory products by disrupting siliyostazi ion transfer system increases. Sinus fluid eosinophils, mononuclear cells and IL-5 producing T-lymphocytes with a predominance of infectious non-inflammation, older children and adults with chronic hyperplastic sinusitis-nasal polyposis syndrome (KHS-NS) can occur. KHS-ns'n half of the patients in the form of allergic asthma or allergic rhinitis accompanies. Asthma or allergic rhinitis clinical symptoms typical of this disease as well elevation of serum IgE and allergen skin test positive are determined.
Acute sinusitis and acute middle ear infection is similar pathogenesis and microbiology. This similarity in acute middle ear infections, antibiotic resistance, associated with the development of information and permits the use in the treatment of sinusitis. In acute and subacute sinusitis, Streptococcus pneumoniae, Haemophilus influenzae (non-type b), and Moraxella catarrhalis are the most common factors. S. pneumoniae accounts for 30-40% of all ages sinus isolates, H. influeanza and M. catarrhalis sinusitis equally and each factor accounted for 20% .. This two beta-lactamase-producing microorganisms can become resistant to amoxicillin. 20% of patients in sinus fluid is sterile and staphylococci, anaerobes in acute bacterial sinusitis are not common factors. Adenovirus, influenza, parainfluenza and rhinovirus is a factor in approximately 10% of patients. In addition to the factors of acute sinusitis in adults with chronic rhinosinusitis Staphylococcus aureus, coagulase-negative staphylococci and anaerobic bacteria are often produced in sinus aspirate cultures. Chronic sinusitis in children the sine culture studies with contradictory results were obtained, anaerobes 0% to 90% was found between cultures some sterile stuck, while in some contamination were evaluated. In one study (Brook et al.), Acute sinusitis, chronic sinusitis period of transition, the initial sinus fluid produced and sensitive to antibiotics, S. pneumoniae, H. influenzae and M. catarrhalis of microorganisms such as initial treatment response of patients recurring sinus cultures re-produced and antibiotic resistance rates to be increased; anaerobic microorganisms have been shown to be added to the table. Two or more of penicillin-resistant pneumococci is highly prevalent in patients receiving antibiotic therapy.
DIAGNOSIS
Under normal circumstances be considered sterile sinus cavities sometimes adjacent nasopharyngeal mucosa flora, bacteria and found to be contaminated Given the paranasal sinus cavity 104 / mL or more bacteria to produce ABS diagnosis is the gold standard. However, invasive sinus aspiration in children is not recommended for routine diagnosis of bacterial sinusitis. Produced in sinus aspirate cultures in the culture of microorganisms often found in the nasopharynx, but enough to predict pathogen in the nasopharynx and sinus culture is not helpful.
ABS diagnosis, symptoms of upper respiratory tract in children presenting with severe symptoms or persistence that is based on clinical criteria, such as. Persistent symptoms, more than 10-14 days before the 30th day lost rode nasal or postnasal discharge (for each property), daytime cough (may be worse at night), or both are associated. In a child with severe symptoms the patient looking 39oc high fever and purulent nasal discharge of 3-4 days is a long time. After upper respiratory tract infections, respiratory symptoms may take until the 10th day, but the relief of symptoms of bacterial complications tend to think. Moderate to severe uncomplicated viral URI with severe symptoms occurring must be separated from ABS. URI viral fever early in the disease, which is associated with symptoms such as headache and myalgia. This constitutional symptoms disappear within two days, respiratory symptoms become apparent. In the first few days of the disease, purulent nasal discharge is not observed. Severe acute sinusitis in patients presenting with symptoms of high fever and purulent nasal discharge for 3-4 days in a row at the same time is seen behind the eyeball can be a headache.
Physical examination is usually not helpful in the diagnosis of ABS. Uncomplicated viral upper respiratory tract infections and acute bacterial sinusitis nasal mucosa with mucopurulent discharge mild erythema and edema are seen. Pain or tenderness in the cheek is rare in children; these findings in children and adolescents with acute bacterial sinusitis symptoms are not reliable. With percussion over the frontal and maxillary bones, or by applying direct pressure induced pain, abscesses can show. Periorbital swelling suggests ethmoid sinusitis.
Respiratory disease in the early stages sinus x-ray, computed tomography and magnetic resonance radiological methods such as sinusitis useful in the diagnosis because it is not a viral URI mucosal edema and osteomeatal complex obstruction of sinus accumulation of fluid in cause by becoming sinusitis radiological findings mimic. Some children may develop on one side of the frontal sinus or no growth. Opacity mistakenly considered as undeveloped sinuses may lead to unnecessary treatment given. Therefore, under the age of sinus films should be evaluated with great care. Put the diagnosis of bacterial sinusitis radiographic methods are not alone. Radiological examination is normal sinus sinusitis is very unlikely. Abnormal radiographic findings reflect inflammation, inflammation, viral, bacterial or allergic in origin does not determine whether. Sinus opacification, mucosal thickening greater than 4 mm or air-fluid levels such as radiographic criteria diagnosed with persistent or severe in 75% of patients with ABS significant bacterial growth in the maxillary sinus aspirates were determined. In another study in children younger than 6 years old during the period of 10-30 days the symptoms of sinusitis, abnormal sinus radiography in 88% of patients predicted, this rate was 70% in children over 6 years of age was observed. Therefore, the clinical criteria used in 60% of children under the age of 6 in sinus bacterial growth is expected to significantly higher predictive value of clinical criteria for the diagnosis of ABS is sufficient. Subject to the requirements of radiography in older children is controversial. Because of the high false-positive rate in this age group sinus radiography, recurrent or refractory to treatment and symptoms of acute bacterial sinusitis is suspected to be done to confirm the diagnosis in cases where there is a trend. Routine diagnosis of acute bacterial sinusitis on computed tomography (CT) is not recommended, because it depends on the viral URI and acute bacterial sinusitis due to changes in the mucosa, which does not distinguish move. IT in these cases should be made: complicated ABS, recurrent or chronic sinusitis cases of surgical treatment of patients with suspected, with ABS in patients with proptosis, visual disturbances, extraocular movements restriction, severe facial pain, received, or so significant swelling, şidetl headache or toxic appearance, if chronic sinusitis do not respond to medical treatment, the sinus and show in detail the anatomy of the surrounding tissue and with the aim to evaluate the indication for surgery.
Antibiotic therapy
To reduce unnecessary antibiotic use in viral URI, and to ensure rational use of antibiotics, the clinical diagnosis of ABS "persistent or severe symptoms of sinus of" must be used. Sinusitis in children with limited number of antibiotics effect was assessed with placebo-controlled double-blind studies (Wald et al. 1986; Garbutt et al., 2001). Wald study treatment on the 3rd day antibiotic in 83% of placebo in 51% of either cure or improvement, while ensuring treatment at day 10 compared to this antibiotic group, 79% in the placebo group to 60% have been reported. ABS is in operation Garbutt diagnosed by clinical criteria and amoxicillin, amoxicillin-clavulanate or placebo for 14 days of therapy in children treated with the recovery rate of 79%, respectively, 81% and 79% have been reported. Garbutt uncomplicated as a result of working in the ABS sinus symptoms for 3 weeks or more to be done in case of persistence of antibiotic therapy will reduce unnecessary antibiotic use and can be used as the first choice of amoxicillin has been concluded. In both studies, sinus symptoms persist longer than 10 days approximately 10% of all cases, including cases in which a small portion formed. These two studies differ in terms of method, although of Garbutt work in the ABS antibiotic treatment of uncomplicated symptoms for a few days before antibiotics can be observed and if improvement is not seen raises the blood.
Although there are different rates in different geographical locations in 10-50% of H. influenzae, M. catarrhalis, in 90-100% of the beta-lactamase production is concerned. In our country, 25-40% of pneumococcal decreased sensitivity to penicillin (MIC 0.1-1.0 mg / ml), between 5-10% of high-level resistance to penicillin (MIC> 2.0 mg / mL) are available. Patients with acute middle ear infection, according to information obtained from the abscess 15% of pneumococcal, H. influenzae and M. catarrhalis sinusitis bound of 50% of the 50-75% resolve spontaneously without treatment. This pneumococcal sinusitis 3% in unresponsiveness amoxicillin, H. influenzae and M. catarrhalis sinusitis sinusitis in 5% 5-10% is expected. Risk factors that increase the likelihood of microorganisms resistant to amoxicillin nursery or nursery school to continue antibiotic treatment in the last 3 months and 2 years old is to be taken. If these factors amoxicillin low dose (45 mg / kg / day divided in 2 doses) response is 80%. If allergy cefuroxime amoxicillin (30 mg / kg / day divided in 2 doses) or cefpodoxime (10 mg / kg / day divided in 2 doses) given. Case of severe allergic reactions clarithromycin (15 mg / kg / day divided in 2 doses), or azithromycin (10 mg / kg / day in a single dose of 4-5 day). Known to be infected with penicillin-resistant pneumococci in children with clindamycin and penicillin allergy (30-40 mg / kg / day in 3 divided doses) may be used. 48-72 of treatment. time of sinus symptoms such as runny nose and cough does not decrease in or sinusitis is wrong or ineffective antibiotics. Patients with low-dose amoxicillin respond if the latest within 90 received antibiotic therapy if moderate-to-severe disease or if nursery / kindergarten persist, amoxicillin-clavulanic acid (80-90 mg / kg / day of amoxicillin and 6.4 mg / kg / day clavulanic acid to contain way) should be treated with. Other options cefuroxime, cefpodoxime, single dose parenteral ceftriaxone (50 mg / kg) with oral antibiotics is to continue after the (initially in patients with vomiting). Initially, trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole may have been used as first or second choice was. Penicillin resistance in pneumococci with increased rates of cross-resistance to these antibiotics amoxicillin responding to the increased use of these antibiotics is not recommended in patients.
Her second course of antibiotics also respond within 2-3 days does not give or acute patients or otolaryngology consultation with the sinus aspirate cultures taken according to the results of antibiotic selection is made or the patient hospitalized intravenous cefotaxime or ceftriaxone therapy is initiated.
Systematic studies on the optimal duration of treatment is 10-14 days, but in the ABS have consensus on the duration of antibiotic therapy. Alternatively symptom free antibiotic may be administered after a further 7 days.
THERAPY ASSISTANT
Buffered saline (SF) to inhibit scale formation of the nasal washes, which dilutes viscous secretions, nasal vasoconstrictor effect on blood flow was shown to be light. In our country, a study conducted in the (lame B gave al.) SF nose drops with patients receiving antibiotics of the patients after 10 days of recovery rates were compared 4 times a day in each nostril 5 drops of SF in patients given the recovery rate of antibiotic one times more were found.
The use of mucolytic drugs, increased production of thick and sticky mucus that may be useful in chronic sinusitis. However, acute sinusitis is not available to studies showing the effectiveness of mucolytic. These drugs of vegetable origin, or that they have a bitter taste, much used by the vagus nerve stimulation as nausea, vomiting and increased mucus secretion may lead to paradoxical.
Topical and systemic decongestant drugs are used to treat acute sinusitis. Decongestants thickening of the nasal mucosa with vasoconstrictor effects have been suggested to reduce. Or noradrenaline on the secretion of alpha-adrenoceptors, are effective on withdrawal or disintegration. Alpha-1 receptors respond to catecholamines vasoconstrictor sympathomimetic most frequently used oral decongestants. Alpha-2 receptors respond to the imidazole derivatives and these drugs are used topically. However, sinusitis topical or systemic vasoconstrictor controlled studies showing the beneficial effects are not available.
Rita developing secondary to allergic rhinitis in the ABS antihistamines, which are used to reduce. However, anticholinergic effects of antihistamines increase the viscosity of secretions of the nose and sinuses, they may lead to further disruption of sinus drainage.
In the adjuvant treatment of abscess in children on the effectiveness of intranasal steroids double-blind, placebo-controlled studies are available only (Barla et al.) In the second week of this study, treatment with intranasal budesonide moderate improvement in the symptoms of sinusitis has provided.
Or hypertonic nasal irrigation with normal saline, antihistamines, decongestants, mucolytic drugs and nasal corticosteroids in the treatment of sinusitis, there are few studies on the effectiveness. Non-antihistamines in allergy associated with the use of drugs is not enough data. Antihistamines and decongestants have no place in the treatment of sinusitis. Sinusitis in children's adjuvant in the treatment of intranasal steroids on the effectiveness of placebo-controlled single systematic study is available (Barla et al.) In this study, intranasal budesonide treatment with 2 weeks of symptoms moderate improvement sağlamıştır.mukolitik and saline systematically been studied.
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