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УЎК:
/615.322
CRITERIA FOR THE TREATMENT OF ACUTE RHINOSINUSITIS
Boboqulova Dilobar Fayzilloyevna
Bukhara State Medical Institute named after Abu Ali ibn Sino, Uzbekistan, Bukhara
e-mail:
Abstract:
Acute rhinosinusitis is one of the most common diseases in the world,
characterized by acute inflammatory processes in the nasal cavity and paranasal sinuses,
lasting less than 4 weeks. According to statistics, in Uzbekistan, this disease is recorded in 6–
15% of the population annually, in European countries in every seventh person, while there is
a tendency to an increase in the incidence. Acute viral rhinosinusitis has the highest incidence
among all rhi nosinusitis and occurs in most patients in a mild form, however, untimely
treatment of inflammation of the nasal mucosa can lead to obstruction of the natural
anastomoses, impaired physiological ventilation and drainage of the paranasal sinuses,
stagnation of secretions with further development acute bacterial rhinosinusitis. The overuse
of local vasoconstrictor drugs (intranasal decongestants) leads to the development of drug-
induced rhinitis,long-term imbalance of autonomic innervation of the nasal mucosa and
edema, called "rebound syndrome". In the article we consider the issues of etiology,
pathogenesis, features of the course of rhinosinusitis. The principles of differential diagnosis
of viral and bacterial rhinosinusitis are stated,taking into account the latest recommendations
and research in this area. The features of the use of the most frequently used topical
preparations in acute rhinosinusitis in the practice of an ENT doctor have been analyzed.
Keywords:
acute rhinosinusitis, herbal medicine, turmeric,respiratory tract.
Introduction
One of the most common acute diseases upper respiratory tract infections among adults is
acute rhinosinusitis (ARS), which is diagnosed in in European countries from 1 to 5%, in the
United States of America ricks – in 16% of the population[1]. In Russia, this disease is
registered from 6 to 15% and amounts to about 10 million cases.
teas per year [2]. In Moscow, the incidence of acute respiratory infections is
1420 cases per 100 thousand adult population [3]. For ORS seasonality is typical: the
incidence of the disease increases in autumn,in winter and early spring and decreases
significantly in warm weather time of year. There is a tendency towards an increase in the
volume of growth of patients with acute and chronic rhinosinusitis volume in outpatient
practice, and the costs of treatment are borne a heavy burden on the health care system [4].
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ARS is defined as an acute inflammatory disease mucous membranes of the nose and
paranasal sinuses, caused by my viruses or bacteria, the duration of which does not exceed 4
weeks [5]. ORS, as a rule, arises is caused by a viral infection that occurs into the paranasal
sinuses from the nasal cavity through natural fistulas, i.e. it cannot occur in isolation [6].The
development of the inflammatory process is accompanied by activation
release of
proinflammatory mediators, destructive
tion of the ciliated epithelium, the development of edema, which leads to inactivation of
mucociliary transport and disruption of sinus aeration [7]. Acute viral rhinosir Nusitis (AVRS)
occurs in 90–98% of cases and in 0.5–2%passes into a bacterial form [8].Increase in
antibiotic-resistant strains of bacteria riy , an increase in the number of viral and allergic
diseases increase the incidence of rhinosinusitis, and not adequate treatment of inflammatory
diseases of the oral cavity of the nose and paranasal sinuses leads to an increase in chronic
ical processes [9].
In this review we present the most relevant information about viral and bacterial sinusitis,
crtheories of differential diagnosis of rhinosinusitis, and also the principles of local therapy in
the treatment of patients with this pathology[10].
Analytical review
Rhinoviruses are most often involved in the development of ardsruses, adenoviruses,
coronaviruses, respiratory syncytial virusesial viruses and parainfluenza viruses.The level of
digital antibodies in the mucous membrane is extremely low due to the penetration of the
virus into the epithelial cells, where its reproduction occurs, immune cascades are launched
response and the recruitment of immune cells with the development of inflammation focus
[11]. ARDS in most cases is flows easily , lasting up to 10 days, and does not requires the
appointment of etiotropic therapy, however, for improving the quality of life and accelerating
recovery of patients[12].
The patient is recommended to prescribe therapy aimed at to reduce the severity of
inflammation symptoms in the nasal cavity [13]. In moderate and severe cases of ARS,
to eliminate the bacterial component of the disease and to avoid prevention of possible
complications is the main method treatment of patients is systemic antibiotic therapy [14].
According to the European guidelines on rhinosinusitis (European position paper on
rhinosinusitis and nasal polyps –EPOS) 2020, a clinical diagnosis is made in the presence of
2 or more symptoms, of which the most important are difficulty in nasal breathing and the
presence of discharge from the nasal cavity or along the back wall of the pharynx, and
additionally negative - a feeling of pressure or pain in the facial
areas, as well as a decrease in the sense of smell . Acute bacterial nal rhinosinusitis (ARS) is
characterized by at least 3 out of 5 symptoms [15]:
1) fever above 38ºC;
2) the second wave of symptoms;
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3) severe pain;
4) one-sided process;
5) increase in erythrocyte sedimentation rate/C-reaction active protein, while the nature of
nasal discharge has less significance.
The main place in the differential diagnosis of viruses of bacterial and ARS is involved in
the analysis of clinical data. One of the important criteria in this case is duration of the
disease, depending on which.
According to EPOS 2020, a distinction is made between:
1) acute sinusitis in adults - characterized by suddenwith the onset of 2 or more symptoms:
congestion nose, nasal discharge, pressure and pain in the places of paranasal sinusectomy,
reduction or loss olfactory impairment, as well as the presence of symptoms for less than 12
weeks;
2) recurrent sinusitis – more than 4 episodes of acute sinusitis per year, with periods of no
symptoms pain;
3) chronic sinusitis - presence of the indicated symptoms lasting more than 12 weeks[16].
If the listed symptoms of ABRS are present, it is necessary possible causes of the disease
must be taken into account. The most more common pathogens of ABRS
includeStreptococcus
pneumoniae,
Haemophilus
influenzae,
Moraxella
catarrhalis,Streptococcus pyogenes and Staphylococcus aureus[17]. The risk factors for ARS
include: smoking, allergic rhinitis,munodeficiency states . In the chronicity of the
disease,anatomical features play a leading role:deviated nasal septum, bulla of the middle
nasal cavity covins, infraorbital cell, structural anomalies uncinate process, additional
anastomosis of the upper maxillary sinus, etc. [18].
Diagnosis of ARS includes an analysis of the patient's medical history.patient, standard
otolaryngological examination,clinical manifestations, laboratory and ininstrumental methods,
and, if necessary,X-ray and computed tomography of the paranasal sinuses. The latter is
widely recommended by European standards for the diagnosis of rhinosinusitis [19].
Microbiological examination of smears from the middle nasal passage or punctate the
inflamed sinus in normal cases ORS is not necessary - this method is used,as a rule, for
scientific purposes . The optimal one is conducting an endoscopic examination of the nasal
cavity and nasopharynx, allowing to assess the state of the intranasal structures and identify
involvement in pathological process of the nearest anatomical formations [20].
The differential sign of ABRS caused by type-typical pathogens (S. pneumoniaeAndH.
influenzae), I'm in the effectiveness of empirical antimicrobial therapy is pii. Initial empirical
therapy for ABRS includes amoxicillin orally 500-1000 mg 3 times a day. When absence of a
noticeable clinical effect aftercillin/clavulanate orally 625 mg 3 times a day or 1000 mg 2
times a day .It is recommended to replace amoxicillin with amoxicillin for 3 days.
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Another option for systemic antibacterial therapy includes oral cephalosporins.III
generation anti-pneumococcal agents with high anti-pneumococcal activity dosage:
cefuroxime axetil 250–500 mg 2 times a day,cefixime 400 mg once daily, cefditoren orally
400 mg 2 times a day [21].
Topical treatment of rhinosinusitis should be prescribed immediately after diagnosis.
According to EPOS 2020, for local treatment of ARS, it is recommended to use intranasal
glucocorticosteroids (InGCS),decongestants, nasal lavage turmeric
solution [22].
Irrigation with turmeric solutions
As a result of exposure to various pathogens in the cavity inflammation of the mucus
occurs in the nose and paranasal sinuses thick membranes, an increase in the viscosity and
amount of nasal mucus – due to an increase in the concentration of mucin .One of the first
things patients can start using even on your own, - irrigation of the nasal cavity with turmeric
solutions. This allows you to remove mucus from the surface [23].
Elimination therapy helps to relieve congestion.Nasal congestion, improving the
rheological properties of mucus,restoration of mucociliary clearance (increase increasing the
activity of cilia - thanks to microelements Ca, Fe, K, Mg, Zn, etc.), reducing swelling and
inflammation,increasing the tone of capillaries . This procedure also allows for improved
penetration of subsequent topical medications: inhaled GCS or decongestants stants [24].
Topical GCS
Long-term disruption of nasal breathing is negative affects cognitive processes, nervous and
servascular system. InGCS are reliably effective for acute respiratory infections and chronic
rhinosinusitis, chronic rhinosinusitis with nasal polyps, as well as with allergic riniti(level of
evidence 1b) . InGCS have powerful anti-inflammatory effect due to suppression inhibition
of the expression of numerous genes involved in inflammation (IL1β, IL2–IL5, IL8, IL13,
IL16, IFNγ, GMCSF, CSF and TNF), molecules of the major histocompatibility complex on
dendritic cells, monocytes and macrophages, as well as modadhesion molecules and
chemokines, while they do not affect the mechanisms of innate immunity and do not change
the immun response to bacterial infection, reduce the duration life of eosinophils and inhibit
the production of immunoglobulins. . In addition, when gene expression is suppressed,MUC-
2 and MUC-5a decrease mucus formation, somewhat swelling in the nasal cavity is reduced
as a result of vasoconstriction ability of InGCS . The latter have low systemic bioavailability
compared to oral and inhaled corticosteroids and show excellent safety profile [25].
Intranasal the route of administration delivers the drug directly to target organ, which
creates a high therapeutic conconcentration. Approximately 30% of the administered dose
settles in nose, the remaining 70% is metabolized in the liver . When assessing the nasal
mucosa that has undergone long-term exposure to InGCS, no significant effect is
observed.Possible side effects are usually limited to non pleasant local reactions such as
irritation,burning in the nose, sneezing, dryness in the frontal parts of the nasal cavities,
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bleeding or sore throat, but often the incidence of these side effects is comparable to those of
taking placebo [26] .
A large number of randomized trials showed that InGCS can be used as a monotherapy for
mild and moderate forms and as an adjuvant juvant agent for systemic antibacterial treatment
treatment of ARS in moderate and severe forms [27].
Decongestants
In case of severe swelling and disruption of the natural passsoot from the paranasal sinuses
is used locally as a sympathomimetics (decongestants) – xylometazoline, oxymetazolinelin,
naphazoline, tetryzoline and phenylephrine. Most vasoconstrictor drugs by the mechanism of
action are is an α-adrenergic agonist: can act on both α1- and α2 -receptors in the walls of
blood vessels, b-due to which there is an increase in tone, a reduction in kavernal tissue of the
nasal conchae. The latter leads to increasing the space in the nasal passages, improving
nobreathing and the removal of pathological secretions one of the paranasal sinuses [28].
In randomized, placebo-controlled studies,statistically significant in comparison with the
results with placebo reduction of subjective symptoms of nasal obstruction after just one dose
of decongestants, which was confirmed by a significant decrease in resistancena sal cavity.
When choosing a decongestant, it is recommended to prescribe paraty in the form of a
metered aerosol of long action action - xylometazoline or oxymetazoline, since pro the
duration of their therapeutic effect reaches 8–12 hours, resulting in the need for too frequent
use [29] .
It should be noted that the use of decongestants is more 10 days can lead to the
development of drug-induced rhinitis. There is a decrease in the number of α-adrenergic
receptors tors on the surface of cell membranes, inhibition of endogenous
production of norepinephrine, decreased sensitivity smooth muscle tissue of the vessels of the
nasal cavity to endogenous norepinephrine, which leads to long-term imbalance of autonomic
innervation of the mucous membrane nose and, as a consequence, swelling of these structures.
This phenomenon the nomenclature was called "rebound syndrome". It also arose changes in
the histological structure of the mucosa are possible nasal membranes towards squamous cell
metaplasia and
glandular hyperplasia [30].
In most cases, the recommended duration of treatment is changes in vasoconstrictor drugs
up to 5–7 days during the development of tachyphylaxis and addiction [31].
Conclusion
A timely and rational approach to local therapy PII ORS allows at the earliest stages of the
disease significantly improve the patient's quality of life, speed up his recovery, as well as
avoiding the chronicity of the disease and its complications. In case of severe obstruction of
the no.The rapid and long-lasting effect of the sovkhods is ensured The use of turmeric is
beneficial.
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