respiraciuli sistemis daavadebebi pirveladi jandacvis rgolis da
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sa qa rT ve lo s<br />

res pir ac iu li as oc ia ci a<br />

sa qa rT ve lo s Sro mi s,<br />

jan mr Te lo bi sa d a<br />

soc ia lu ri d ac vi s<br />

sa mi ni st ro<br />

mwvave <strong>respiraciuli</strong> infeqciis<br />

marTvis gaidlaini<br />

av tore bi: i.C xa iZe , T. ma Rlak eliZe, q. nems aZ e,<br />

m.xe rx euliZe, n.ya vl aS vili, e. kand elak i, q. ba ra ba Ze<br />

eq sp er te bi: S.j af ariZe , e.va Sa ki Ze , m.x oWav a, q.H Sa ra ngia<br />

Tb ilisi<br />

20 06<br />

Se savali<br />

<strong>respiraciuli</strong> <strong>sistemis</strong> <strong><strong>da</strong>avadebebi</strong> <strong>pirveladi</strong> <strong>jan<strong>da</strong>cvis</strong> <strong>rgolis</strong><br />

<strong>da</strong>wesebulebebSi mimarTvianobis ZiriTad mizezs warmoadgenen. mwvave<br />

<strong>respiraciuli</strong> infeqciebis maRali sixSire praqtikuli medicinis

seriozul problemad rCeba. gasaTvaliswinebelia sakiTxis socialuri<br />

mniSvnelobac – mwvave <strong>respiraciuli</strong> paTologiiT avadoba qveynisaTvis<br />

seriozuli ekonomikuri tvirTia, romlis Semadgenelia rogorc uSualod<br />

mkurnalobaze <strong>da</strong>xarjuli Tanxa, ise droebiTi SromisuunarobiT<br />

gamowveuli <strong>da</strong>nakargebi.<br />

mwvave <strong>respiraciuli</strong> paTologiis gaidlainSi ganxiluli iqneba zemo<br />

sasunTqi gzebis mwvave paTologia. qvemoT moyvanili diagrama asaxavs<br />

gaidlainis organizacias:<br />

mwvave <strong>respiraciuli</strong><br />

paTologia<br />

zemo sasunTqi gzebis mwvave<br />

paTologia<br />

qvemo sasunTqi gzebis mwvave<br />

paTologia<br />

otiti<br />

pnevmonia<br />

bronqiti<br />

gacieba<br />

sinusiti<br />

faringiti<br />

winamdebare gaidlainSi moyvanilia stacionarSi mwvave otitis,<br />

sinusitis, faringitis <strong>da</strong> gaciebis marTvis Tanamedrove rekomen<strong>da</strong>ciebi.<br />

gaidlaini mniSvnelovania ori TvalsazrisiT. pirvel rigSi, is aRwers<br />

diagnostikisa <strong>da</strong> mkurnalobis im problemebs, romlebTanac eqimebs<br />

yoveldRiuri Sexeba aqvT. meores mxriv, am <strong>da</strong>avadebaTa marTva xSirad<br />

Seusabamo medikamentebiT xdeba, gansakuTrebiT es exeba antibiotikebs.<br />

antibiotikebis gamoyeneba maSin, rodesac is aucilebeli ar aris; meore <strong>da</strong><br />

mesame Taobis antibiotikebis gamoiyeneba maSin, rodesac pirveli Taobisaa<br />

saWiro – yvelaferi es <strong>jan<strong>da</strong>cvis</strong> seriozul problemas qmnis: yalibdeba<br />

baqteriebis antibiotikebis mimarT rezistentuli Stamebi. amitom am<br />

gaidlainSi gansazRvruli iqneba antibiotikis adeqvaturi gamoyenebis<br />

2

Cvenebebi, romelic saSualebas miscems eqims <strong>da</strong>icvas medicinis erT-erTi<br />

mTavari postulati – premium non nocere (ar avno).<br />

gaidlainebSi moyvanili informacia Sefasebulia faqtebze<br />

<strong>da</strong>myarebuli medicinis (Evi<strong>da</strong>nce Based Medicine) sarwmunoebis TvalsazrisiT.<br />

done<br />

I<br />

II<br />

II I<br />

IV<br />

Va<br />

V b<br />

mtkicebulobis done <strong>da</strong> rekomen<strong>da</strong>ciis xarisxi<br />

mtkicebulebis siZlieris<br />

done<br />

Zlieri mtkicebuleba,<br />

eyrdnoba minimum erT<br />

sistemur mimoxilvas,<br />

romelic efuZneba swori<br />

dizainis mqone<br />

randomizebul<br />

kontrolirebadi kvlevas<br />

Zlieri mtkicebuleba,<br />

eyrdnoba minimum erT<br />

swori dizainis mqone<br />

randomizebul<br />

kontrolirebadi kvlevas<br />

klinikuri kvleva<br />

randomizaciis gareSe,<br />

kohortuli <strong>da</strong> SemTxvevakontrolis<br />

kvlevebi<br />

araeqsperimentuli<br />

multicentruli kvlevebi<br />

avtoritetul<br />

profesionalTa<br />

mosazreba<br />

klinikuri gamocdileba,<br />

aRwerilobiTi kvlevebi<br />

an eqspertTa angariSi<br />

xarisxi<br />

A<br />

B<br />

C<br />

D<br />

rekomen<strong>da</strong>ciis<br />

xarisxi<br />

eyrdnoba I donis<br />

mtkicebulebas <strong>da</strong><br />

Sesabamisad<br />

mtkiced<br />

rekomendebulia<br />

eyrdnoba II donis<br />

mtkicebulebas <strong>da</strong><br />

Sesabamisad<br />

rekomendebulia<br />

eyrdnoba III<br />

donis<br />

mtkicebulebas <strong>da</strong><br />

SeiZleba<br />

CaiTvalos<br />

Sesabamisad<br />

eyrdnoba IV <strong>da</strong> V<br />

donis<br />

mtkicebulebas,<br />

saWiroebs<br />

konsesuss<br />

mwv av e far ing iti<br />

gaidlainis aucilebloba. SemTxvevaTa umravlesobaSi mwvave<br />

faringiti msubuqad mimdinareobs <strong>da</strong> ar saWiroebs mkurnalobas. mas<br />

mxolod erTeuli mogvianebiTi garTulebebi axasiaTebs. miuxe<strong>da</strong>vad amisa,<br />

xSirad mwvave faringitis dros aqtiurad iyeneben antibiotikebs, romelTa<br />

aucilebloba <strong>da</strong><strong>da</strong>sturebuli ar aris <strong>da</strong>, amave dros, maTi <strong>da</strong>niSvna<br />

mniSvnelovnad aZvirebs mkurnalobas.<br />

3

pacientebis nawili xdeba yel-yur cxviris eqimTan, romelic xSirad<br />

irCevs operaciul Carevas, romlis aucilebloba emyareba pirad<br />

gamocdilebas <strong>da</strong> ara faqtebze <strong>da</strong>myarebul rekomen<strong>da</strong>ciebs.<br />

mwvave faringitis gaidlaini emyareba literaturis sistemur<br />

mimoxilvas <strong>da</strong> faqtebze <strong>da</strong>myarebuli medicinis rekomen<strong>da</strong>ciebs. gaidlaini<br />

ganixilavs mwvave faringitis optimalur marTvas, ramac xeli un<strong>da</strong><br />

Seuwyos: (a) <strong>da</strong>avadebis mZime formebis ricxvis Semcirebas; (b) mwvave<br />

revmatuli cxelebiT avadobis Semcirebas; (g) garTulebebebis prevencias;<br />

(d) Seusabamo antibiotikoTerapiis uaryofiTi zegavlenis Semcirebas.<br />

definicia. mwvave faringiti orofaringealuri aris anTebiTi<br />

procesia. mwvave faringiti SeiZleba aRwerili iqnes rogorc “yelis<br />

tkivili” (avadmyofobaTa saerTaSoriso klasifikaciis meaTe ga<strong>da</strong>xedvis<br />

mixedviT is Seesabameba mwvave faringits - J02).<br />

epidemiologia. epidemiologiuri monacemebi gansxvavebulia qveynebis<br />

mixedviT. weliwadSi mwvave <strong>respiraciuli</strong> infeqciiT aSS-Si erTi bavSvi<br />

saSualod 5-jer xdeba avad, maSin rodesac streptokokuli infeqciiT -<br />

mxolod erTxel yovel 4 weliwadSi. mozrdilebSi zemoaRniSnuli<br />

monacemebis sixSire saSualod 50%-iT naklebia. sxva qveynebSi mwvave<br />

faringitis sixSire Se<strong>da</strong>rebiT maRalia. gansakuTrebiT maRalia<br />

antibiotikebisadmi rezistentuli Stamebis ricxvi, rac antibiotikebis<br />

araracionaluri gamoyenebiT aixsneba (sarwmunoebis done II).<br />

mwvave faringitis sixSire Se<strong>da</strong>rebiT maRalia gviani Semodgomi<strong>da</strong>n<br />

adreuli gazafxulis perio<strong>da</strong>mde. igi ufro xSiria 5-10 wlis <strong>da</strong> 15-25 wlis<br />

asakSi.<br />

saqarTveloSi mwvave faringitis, iseve rogorc sinusitis an otitis<br />

monacemebi cal-calke ar registrirdeba. saqarTvelos <strong>da</strong>avadebaTa<br />

kontrolis <strong>da</strong> samedicino statistikis centris 2005 wlis monacemebiT<br />

qveyanaSi registrirebul iqna qronikuli faringitis, nazofaringitis <strong>da</strong><br />

sinusitis 21.553 SemTxveva, rac 100.000 mosaxleze 493 SemTxvevas<br />

warmoadgens. bavSvebSi registrirebuli iqna 7.322 SemTxveva, rac 100.000<br />

bavSvze 799 SemTxvevas warmoadgens. amave wels saqarTveloSi<br />

registrirebul iqna nuSura jirkvlebis <strong>da</strong> <strong>da</strong>namati Rruebis qronikuli<br />

<strong>da</strong>avadebis 22.781 SemTxveva, rac 100.000 mosaxleze 521 SemTxvevas<br />

warmoadgens. bavSvebSi registrirebuli iqna 12.679 SemTxveva, rac 100.000<br />

bavSvze 1.384 SemTxvevas warmoadgens.<br />

etiologia.<br />

ZiriTad etiologiur faqtors warmoadgens virusi (40%) <strong>da</strong><br />

baqteriuli (30%) flora. yelis tkivilis gamomwvevi SeiZleba iyos<br />

agreTve qimiuri (sigaretis moweva), meqanikuri agenti (nakawri, naCxapni<br />

4

Zvlis fragmentiT), alergia an postnazaluri wveTi an iSviaTad kibo<br />

(adreul stadiaSi kibo xSirad vlindeba tkivilis simptomiT).<br />

faringitis gamomwvevi ZiriTadi virusebia adenovirusi, rinovirusi,<br />

koronavirusi, eqovirusi, koksaki, gripis <strong>da</strong> paragripis virusi. Se<strong>da</strong>rebiT<br />

iSviaTia epStein-baris virusi, citomegalovirusi, martivi herpesis virusi.<br />

Α jgufis β hemolizuri streptokoki ganapirobebs faringitis<br />

SemTxvevaTa 10-15%-s mozrdilebSi <strong>da</strong> 30%-s bavSvebSi.<br />

sxva gamomwvevebia: Corynebacterium diphtheriae; Corynebacterium hemolyticum,<br />

Chlamydia pneumoniae, Mycoplasma pneumoniae. bavSvebSi sxva paTogenuri flora<br />

SeiZleba iyos: Staphylococus aureus, Haemophilus catarralis, Bacteroides fragilis,<br />

Bacteroides lannogenius, Fuzobacterium species, Peptostreptococcus species.<br />

paTofiziologia. infeqciuri faringitis SemTxvevaSi baqteria <strong>da</strong><br />

virusi SeiZleba pir<strong>da</strong>pir SeiWras lorwovan garsSi <strong>da</strong> gamoiwvios<br />

anTebiTi procesi. zogi gamomwvevi, magaliTad rinovirusi, xaxis<br />

lorwovanis <strong>da</strong>zianebas ganapirobebs meora<strong>da</strong>d, rinitis ganviTarebis<br />

Semdeg. streptokokuli infeqcia xasiaTdeba lokaluri invaziiT <strong>da</strong><br />

ujredgareT toqsinebis <strong>da</strong> proteinebis gamoTavisuflebiT. gar<strong>da</strong> amisa,<br />

streptokokis zogierTi serotipis M-proteinis fragmentebi miokardiumis<br />

antigenis msgavsia <strong>da</strong>, aqe<strong>da</strong>n gamomdinare, ukavSirdeba revmatul cxelebas<br />

<strong>da</strong> SemdgomSi gulis sarqvlis <strong>da</strong>zianebas. streptokokuli infeqciiT<br />

ganpirobebulia aseve mwvave glomerulonefriti, romelsac iwvevs antigenantisxeulis<br />

kompleqsis depozicia glomerulebSi.<br />

klinikuri suraTi. faringitis klasikuri simptomebi moicaven<br />

yelis tkivils, disfagias, cxelebas, saerTo sisustes, Tavis tkivils.<br />

obieqturi gamokvlevisas vlindeba xaxisa <strong>da</strong> nuSura jirkvlebis anTebiTi<br />

cvlilebebi (hiperemia, Sesiveba), Cirqovani nadebi nuSura jirkvlebze,<br />

kisris wina limfuri jirkvlebis Sesiveba. arc erTi es niSani ar aris<br />

paTognomuri streptokokuli etiologiis faringitisaTvis, Tumca maTi<br />

arsebobis SemTxvevaSi <strong>da</strong>aadebis baqteriuli etiologia ufro<br />

SesaZlebelia.<br />

cxviri<strong>da</strong>n gamonadeni, xvela, xmis CaxleCa, koniunqtiviti <strong>da</strong> diarea<br />

iSviaTia, <strong>da</strong> Tu es niSnebi gamoCn<strong>da</strong>, safiqrebelia <strong>da</strong>avadebis virusuli<br />

etiologia. streptokokuli etiologiisaTvis <strong>da</strong>maxasiaTebelia aseve<br />

temperaturis uecari mateba (38 0 -ze meti) Semcivnebis gareSe.<br />

iSviaTad mwvave faringiti SeiZleba iyos mwvave epiglotitis an zemo<br />

sasunTqi gzebis sxva seriozuli <strong>da</strong>avadebis gamovlena.<br />

stacionarSi moTavseba iSviaTad aris aucilebeli. aseTia<br />

peritonzilaruli celulitis an abscesis SemTxvevebi, rodesac saWiroa<br />

5

otolaringologis meTvalyureoba <strong>da</strong> parenteraluri antibiotikebi.<br />

iSviaTad hospitalizaciis mizezi SeiZleba gaxdes disfagia an<br />

dehidratacia.<br />

yelis tkivilTan erTad arsebuli stridori an sunTqvis gaZneleba<br />

hospitalizaciis saswrafo Cvenebas warmoadgens.<br />

diagnostika.<br />

ar aris monacemebi, romlebic <strong>da</strong>a<strong>da</strong>stureben, rom baqteriuli<br />

faringiti ufro mZimed mimdinareobs, vidre virusuli, an rom <strong>da</strong>avadebis<br />

xangrZlivoba gansxvavdeba etiologiis mixedviT. mwvave faringitis<br />

diagnozi SeiZleba <strong>da</strong>eyrdnos klinikur niSnebs an laboratoriul<br />

gamokvlevebs. stacionarSi uxSiresad iyeneben xaxis nacxis<br />

baqteriologiur gamokvlevas an antigenis deteqciis swraf tests (RAT).<br />

k l i n i k u r i d i a g n o z i . <strong>da</strong>avadebis klinikuri gamovlinebani<br />

arasakmarisia baqteriuli <strong>da</strong> virusuli etiologiis sadiferenciacioT.<br />

specifiurobis <strong>da</strong> mgrZnobelobis kvlevam aCvena, rom mxolod klinikur<br />

niSnebze <strong>da</strong>yrdnobiT mwvave faringitis SemTxvevaTaA25-30% rCeba<br />

diagnostikis gareSe <strong>da</strong> SemTxvevaTa 20-40%-Si negatiuri baqteriologiuri<br />

pasuxis miuxe<strong>da</strong>vad <strong>da</strong>smuli iqnebo<strong>da</strong> streptokokuli faringitis<br />

diagnozi (sarwmunoebis done II).<br />

<br />

baqteriuli <strong>da</strong> virusuli etiologiis faringitis diferencirebas<br />

ar un<strong>da</strong> <strong>da</strong>edos safuZvlad <strong>da</strong>avadebis klinikuri niSnebi.<br />

b a q t e r i o l o g i u r i k v l e v a . baqteriologiuri kvlevis <strong>da</strong>debiTi<br />

Sedegi a<strong>da</strong>sturebs <strong>da</strong>avadebis streptokokul etiologias, Tumca<br />

uaryofiTi pasuxi ar gamoricxavs <strong>da</strong>avadebis baqteriul etiologias.<br />

gar<strong>da</strong> amisa, aris SemTxvevebi, rodesac xaxis nacxi<strong>da</strong>n izolirebulia<br />

streptokoki, Tumca infeqcia serologiurad ar <strong>da</strong>sturdeba. SemTxvevaTa<br />

40%-Si aseve aRniSnulia streptokokis asimptomuri mtarebloba. nuSura<br />

jirkvelebis ze<strong>da</strong>piri<strong>da</strong>n aRebuli flora yovelTvis ar Seesabameba<br />

tonzilebis siRrmi<strong>da</strong>n miRebul masalas, ara<strong>da</strong> swored es ukanaskneli<br />

aris pasuxismgebeli <strong>da</strong>avadebis ganviTarebaze. serologiurad<br />

<strong>da</strong><strong>da</strong>sturebuli infeqciis SemTxvevaSi xaxis nacxi ar xasiaTdeba maRali<br />

specifiurobiT <strong>da</strong> mgrZnobelobiT. is aseve zrdis <strong>da</strong>avadebis Rirebulebas<br />

<strong>da</strong> SeiZleba ganapirobos araaucilebeli medikamenturi mkurnaloba<br />

(sarwmunoebis done III).<br />

<br />

mwvave faringitis SemTxvevaSi xaxis nacxis baqteriolgiuri kvleva<br />

ar un<strong>da</strong> Catardes rutinulad.<br />

a n t i g e n i s d e t e q c i i s s w r a f i t e s t i ( R A T ) . stacionarSi<br />

SeiZleba gamoyenebuli iqnes antigenis deteqciis swrafi testi. xaxis an<br />

6

nuSura jirkvlebis nacxSi streptokokis antigenis gansazRvris testis<br />

upiratesobaa misi siswrafe <strong>da</strong> maRali specifiuroba (95-100%). misi<br />

gamoyenebiT SesaZlebelia aseve SeizRudos antibiotikebis gaumarTlebeli<br />

gamoyeneba. mis ZiriTad uaryofiT mxares warmoadgens meTodis <strong>da</strong>bali<br />

mgrZnobeloba (50-95%).<br />

s e r o l o g i u r i d i a g n o s t i k a . avadmyofis organizmis imunur<br />

pasuxze vlaparakobT maSin, rodesac antistreptolizinis, ant-dnm-is, an<br />

sxva antistreptokokuli antisxeulebis titri 4-jer matulobs.<br />

imunoserologiuri kvleva streptokokuli infeqciis erT-erTi saimedo<br />

meTodia, Tumca misi mgrZnobeloba mcirdeba antibaqteriuli Terapiis<br />

fonze. <strong>da</strong>avadebis mwvave periodSi antistreptokokuri antisxeulebis<br />

titri maqsimums aRwevs me-2-3 kviras.<br />

yovelive zemoaRniSnuli<strong>da</strong>n ganasxvaveben streptokokuli faringitis<br />

4 tips:<br />

1. streptokokuli faringiti: tipuri klinikuri suraTi,<br />

baqteriologiuri <strong>da</strong> serologiuri kvlevis <strong>da</strong>debiTi<br />

Sedegebi;<br />

2. SesaZlo streptokokuli faringiti: tipuri klinikuri<br />

suraTi, baqteriologiuri kvlevis <strong>da</strong>debiTi Sedegi,<br />

serologiuri kvlevis SeuZlebloba;<br />

3. mtarebloba: tipuri klinikuri suraTi an usimptomo<br />

mimdinareoba, baqteriologiuri kvlevis <strong>da</strong>debiTi Sedegi,<br />

uaryofiTi serologiuri pasuxi;<br />

4. kolonizacia: usimptomo mimdinareoba, baqteriologiuri<br />

kvlevis <strong>da</strong>debiTi Sedegi.<br />

marTva. mwvave faringitis diagnozi ar niSnavs, rom aucileblad<br />

un<strong>da</strong> <strong>da</strong>iniSnos antibiotiki. adeqvaturi tkivilgamayuCebeli saSualebebi<br />

xSirad savsebiT sakmarisia mkurnalobisaTvis.<br />

t k i v i l g a m a y u C e b e l i s a S u a l e b e b i . pacientTa umravlesoba<br />

arasodes ar mimarTavs eqims, vinai<strong>da</strong>n simptomuri saSualebebi aspirinis an<br />

paracetamolis saxiT savsebiT sakmarisia mkurnalobisaTvis. aqve un<strong>da</strong><br />

aRiniSnos, rom reis sindromis ganviTarebis riskis gamo bavSvebSi<br />

aspirinis gamoyeneba ar aris <strong>da</strong>Svebuli.<br />

a r a s t e r o i d u l i a n T e b i s s a w i n a a R m d e g o s a S u a l e b e b i .<br />

mravali kvleva aRwers arasteroiduli anTebis sawinaaRmdego<br />

saSualebebis gamoyenebas mwvave faringitis <strong>da</strong> tonzilitis dros.<br />

naCvenebia, rom mkurnalobis ori-sami dRis Semdeg ufro swrafad xdeba<br />

tkivilis, cxelebis, disfagiis, xiluli hiperemiis, limfadenopaTiis<br />

Semcireba placebosTan an paracetamolTan Se<strong>da</strong>rebiT. Tumca un<strong>da</strong><br />

7

aRiniSnos, rom mwvave faringitis an tonzilitis simptomebi TavisTavad<br />

mcirdeba <strong>da</strong>avadebis <strong>da</strong>wyebi<strong>da</strong>n 48-72 saaTis Semdeg (sarwmunoebis done I).<br />

amave dros, arasteroiduli anTebis sawinaaRmdego saSualebebis<br />

gamoyeneba <strong>da</strong>kavSirebulia gastrointestinaluri sisxldenis, gulisrevis,<br />

Rebinebis, muclis tkivilis <strong>da</strong> diareis ganviTarebis <strong>da</strong><strong>da</strong>sturebul<br />

riskTan.<br />

<br />

arasteroiduli anTebis sawinaaRmdego saSualebebis gamoyenebis<br />

riskis gamo maTi rutinuli gamoyeneba mwvave faringitis dros<br />

rekomendebuli ar aris.<br />

d a m a t e b i T i T e r a p i a . erTeul kvlevebSi aris <strong>da</strong><strong>da</strong>sturebuli<br />

savlebi saSualebebis (benzi<strong>da</strong>minis hidroqloridis) efeqturoba tkivilis<br />

<strong>da</strong> disfagiis Semcirebis TvalsazrisiT, magram es Sedegebi Semdgom<br />

<strong>da</strong><strong>da</strong>sturebas moiTxoven (sarwmunoebis done I).<br />

a n t i b i o t i k e b i s g a m o y e n e b a .<br />

antibitikebi mwvave faringitis dros. mwvave faringitis yvela<br />

SemTxveva ar aris baqteriuli etiologiis, ase rom alogikuria mwvave<br />

faringitis yvela SemTxvevaSi gamoyenebul iqnes antibiotiki.<br />

Ria kvlevaSi, romelic 700 pacientSi Seiswavli<strong>da</strong> mkurnalobis<br />

sxva<strong>da</strong>sxva reJimis efeqturobas (antibiotiki, antibiotikis gareSe,<br />

antibiotikis <strong>da</strong>niSvna sami dRis <strong>da</strong>gvianebiT) naCvenebia, rom am jgufebs<br />

Soris <strong>da</strong>avadebis gamosavalis TvalsazrisiT gansxvaveba ar aris<br />

(sarwmunoebis done I).<br />

ar arsebobs sakmarisi informacia, romelis <strong>da</strong>a<strong>da</strong>sturebs<br />

antibiotikebis rutinuli gamoyenebis aucileblobas mwvave faringitis<br />

dros.<br />

<br />

<strong>da</strong>avadebis mZime mimdinareobisas, rodesac pacientis zogadi<br />

mdgomareoba mZimea, antibiotiki un<strong>da</strong> iqnes gamoyenebuli<br />

(penicilini V 250 4-jer an 500 mg 2-jer an 4-jer dReSi 10 dRis<br />

ganmavlobaSi; bavSvebSi 250 mg 2-jer an 3 jer dReSi, 10 dRe per os)<br />

an<br />

penicilini G (benzatin penicilini) erTjera<strong>da</strong>d kunTebSi, 1.200.000<br />

mozrdilebSi, 27 kg-mde wonis bavSvebSi – 600.000.<br />

eqimma un<strong>da</strong> gaiTvaliswinos, rom mZime faringiti <strong>da</strong> kisris<br />

limfuri jirkvlebis gadideba SeiZleba infeqciuri mononukleozis<br />

niSani iyos, amitom un<strong>da</strong> moeridos pirveli rigis preparatad<br />

ampicilinis gamoyenebas.<br />

<br />

amerikis pediatriis akademiis <strong>da</strong> <strong>da</strong>avadebaTa kontrolis centris<br />

(CDC) mier rekomendebulia amoqsicilinis gamoyeneba meore rigis<br />

8

preparatad rezistentul floraze misi upiratesi zemoqmedebis<br />

gamo.<br />

penicilinze alergiis SemTxvevaSi mizanSewonilia makrolidebis<br />

gamoyeneba. eriTromicinis gamoyeneba misi gverdiTi movlenebis<br />

(gulisreva, diarea) SezRudulia. rig kvlevebSi naCvenebia axali<br />

Taobis makrolidebis (spiramicini, azitromicini) efeqturoba<br />

baqteriologiuri <strong>da</strong> klinikuri monacemebis gaumjobesebis<br />

TvalsazrisiT.<br />

(sarwmunoebis done II).<br />

antibiotikebi morecidive fa ringitis dros. mwvave faringitis<br />

morecidive mimdinareoba im pacientebSi, romlebic iRebdnen antibiotikebs,<br />

miuTiTebs, rom gamoyenebul iqna Seusabamo antibiotiki, antibiotiki<br />

<strong>da</strong>niSnuli iyo araadeqvaturi doziT an xangrZlivobiT, pacienti ar<br />

<strong>da</strong>emorCila mkurnalobas, aRiniSna re-infeqcia an <strong>da</strong>avadebis gamomwvevi<br />

iyo penicilin-rezistentuli beta-laqtamazis maproducirebeli Stamebi.<br />

aseT SemTxvevebSi naCvenebia benzatin-penicilinis (penicilini G),<br />

cefuroqsimis an klin<strong>da</strong>micinis gamoyeneba (sarwmunoebis done I <strong>da</strong> III).<br />

ar arsebobs sakmarisi informacia, romelic <strong>da</strong>a<strong>da</strong>sturebs<br />

antibiotikebis gamoyenebis aucileblobas mwvave morecidive<br />

arastreptokokuli faringitis dros.<br />

streptokokTan asocirebuli morecidive faringitis dros<br />

mcirericxovani kvlevebia, romlebic gvi<strong>da</strong>stureben 10 dRiani<br />

antibiotikoTerapiis efeqturobas gamwvavebaTa sixSiris Semcirebis<br />

TvalsazrisiT.<br />

ar arsebobs sarwmuno informacia, romelic <strong>da</strong>a<strong>da</strong>sturebs<br />

streptokokuli faringitis profilaqtikis mizniT antibiotikebis<br />

xangrZlivi gamoyenebis efeqturobas.<br />

<strong>da</strong>matebiTi Terapia morecidive fa ringitis dros.<br />

randomozebuli, ormagi brma, placebo-kontrolirebadi<br />

multicentruli kvleviT <strong>da</strong><strong>da</strong>sturebulia imunoaqtiuri baqteriuli<br />

eqstraqtiT (OM-85, bronqo-vaqsomi, saqarTveloSi registrirebulia<br />

bronqo-munali) imunostimulaciis mniSvneloba zemo sasunTqi gzebis<br />

morecidive infeqciebis (morecidive faringiti) dros.<br />

antibiotikebi revmatuli cxelebis <strong>da</strong> glomerulonefritis<br />

prevenciisaTvis.<br />

streptokokuli faringitis mkurnalobis erT-erTi <strong>pirveladi</strong><br />

klinikuri racionalizmi revmatuli cxelebis Tavi<strong>da</strong>n acilebaSi<br />

mdgomareobs. analogiuri Sexedulebaa glomerulonefritTan<br />

<strong>da</strong>kavSirebiT. Tumca un<strong>da</strong> aRiniSnos, rom ar arsebobs kvlevebi, romlebic<br />

9

miuTiTeben antibiotikoTerapiis efeqturobas glomerulone-fritis<br />

prevenciis mizniT (sarwmunoebis done II).<br />

tonzileqtomia morecidive faringitis dros<br />

literaturuli monacemebi tonzileqtomiis Sesaxeb Zalian mcirea <strong>da</strong><br />

ar xasiaTdeba samecniero sarwmunoebiT. 80-ian wlebSi bevr qveyanaSi<br />

farTod iyo miRebuli kriteriumi, romlis Tanaxmad tonzileqtomia<br />

keTdebo<strong>da</strong> maSin, rodesac bolo wels aRiniSnebo<strong>da</strong> tonzilitis 7<br />

epizodi, an bolo 2 wels 5 epizodi yovelwliurad an bolo 3 wels 3<br />

epizodi yovelwliurad. es kriteriumebi ar iTvaliswinebdnen avadmyofis<br />

zogadi mdgomareobis dinamikas, gansxvavebas mozrdilebsa <strong>da</strong> bavSvebs<br />

Soris <strong>da</strong> a.S.<br />

SeiZleba vivaraudoT, rom morecidive tonzilitis epizodebis<br />

prevencia SesaZlebelia operaciuli CareviT, magram tonzileqtomia ar<br />

iZleva sxva mizezebiT ganpirobebuli morecidive faringitis prevenciis<br />

saSualebas. aqe<strong>da</strong>n gamomdinare, tonzileqtomiis win morecidive<br />

tonzilitis diagnozi un<strong>da</strong> iyos <strong>da</strong>zustebuli <strong>da</strong> diferencirebuli<br />

generalizebuli faringitisagan.<br />

tonzileqtomia saWiroebs xanmokle hospitalizacias, zogad<br />

anesTezias, <strong>da</strong> SesaZlebelia garTuldes sisxldeniT. cxovrebis Cveul<br />

ritmTan <strong>da</strong>bruneba saSualod 2 kvira saWiroebs, Sesabamisad es dro<br />

<strong>da</strong>kargulia swavlis an muSaobisaTvis.<br />

sarwmuno kvlevebis simciris miuxe<strong>da</strong>vad, mraval arakontrolirebad<br />

kvlevaSi aRniSnulia tonzileqtomiis sargeblianoba ara mxolod<br />

faringitis epizodebis Semcirebis, aramed zogadi janmrTelobis<br />

gaumjobesebis TvalsazrisiT (sarwmunoebis done II <strong>da</strong> III).<br />

qvemoT moyvanilia tonzileqtomiis kriteriumebi rogorc<br />

mozrdilebis, ise bavSvebisaTvis. pacientebi un<strong>da</strong> akmayofilebdnen yvela<br />

qvemoT CamoTvlil kriteriums:<br />

mwvave faringitis mizezi un<strong>da</strong> iyos tonziliti;<br />

erTi wlis ganmavlobaSi un<strong>da</strong> aRiniSnos mwvave faringitis 5 an<br />

meti epizodi;<br />

simptomebi un<strong>da</strong> grZeldebodes sul mcire erTi wlis<br />

ganmavlobaSi;<br />

mwvave faringitis mimdinareoba iseTi mZime un<strong>da</strong> iyos, rom xels<br />

uSlides avadmyofis normalur yoveldRiur saqmianobas<br />

(sarwmunoebis done II <strong>da</strong> III, rekomen<strong>da</strong>cia C).<br />

gasaTvaliswinebelia aseve, rom xSir SemTxvevaSi Zneli <strong>da</strong>sadgenia<br />

mwvave faringitebis zusti sixSire an iyo Tu ara mwvave faringitis mizezi<br />

10

ealurad mwvave tonziliti. amitom, rekomendebulia tonzileqtomiamde 6<br />

Tviani <strong>da</strong>kvirvebis periodi, romlis ganmavlobaSi zustdeba yelis<br />

tkivilis gamomwvevi mizezebi. mas Semdeg, rac ga<strong>da</strong>wyvetileba miRebuli<br />

iqneba, operacia un<strong>da</strong> Catardes rac SeiZleba swrafad.<br />

mw va ve si nu siti<br />

definicia<br />

sinusiti paranazaluri sinusebis lorwovani garsis anTebaa. sinusiti<br />

warmoadgens nazaluri ubnis lorwovani garsis momijnave aris Tanmxleb<br />

anTebiT process (avadmyofobaTa saerTaSoriso klasifikaciis meaTe<br />

ga<strong>da</strong>xedvis mixedviT is Seesabameba mwvave sinusits - J01). sinusitis<br />

ganviTareba uxSiresad iwyeba rinitis fonze, ris gamoc mas xSir<br />

SemTxvevaSi uwodeben rinosinusits.<br />

arCeven mwvave, qvemwvave <strong>da</strong> qronikul sinusits:<br />

mwvave sinusitis xangrZlivoba naklebia 4 kviraze. mwvave sinusiti<br />

cxviris <strong>da</strong>namati Rruebis lorwovani garsis anTebiTi <strong>da</strong>zianebaa,<br />

romelic gamowveulia baqteriebis zrdiT <strong>da</strong>xSul RruSi.<br />

qvemwvave (baqteriuli) sinusiti baqteriuli infeqciiT gamowveuli<br />

cxviris <strong>da</strong>namati Rruebis lorwovani garsis anTebiTi <strong>da</strong>zianebaa,<br />

11

omelic grZeldeba 30-<strong>da</strong>n 90 dRemde <strong>da</strong> romlis Semdeg simptomebi<br />

mTlianad ixsneba;<br />

morecidive sinusitis diagnozi ismeba im SemTxvevaSi, Tu sinusitis<br />

epizodebis sixSirea 4 an metia weliwadSi, TiToeuli epizodis<br />

xangrZlivobaa 10 dRe <strong>da</strong> meti, <strong>da</strong> Tu gamwvavebaTa Soris periodSi<br />

pacients simptomatika ar uvlindeba;<br />

qronikuli sinusiti grZeldeba 12 kvira <strong>da</strong> meti mkurnalobis fonze an<br />

mis gareSe.<br />

epidemiologia<br />

Cveulebriv mozrdili a<strong>da</strong>miani wlis ganmavlobaSi 3-4 jer avadobs<br />

mwvave <strong>respiraciuli</strong> infeqciiT, bavSvTa asakSi mri-s sixSire<br />

gacilebiTYmetia <strong>da</strong> Seadgens <strong>da</strong>axloebiT 6-10 weliwadSi. mri-s<br />

SemTxvevaTa <strong>da</strong>axloebiT 0,5-2%, xolo sxva avtorTa monacemebiT 7%,<br />

rTuldeba baqteriuli sinusitiT. un<strong>da</strong> aRiniSnos, rom virusuli<br />

rinosinusiti 200-jer ufro xSiria, vidre baqteriuli.<br />

etiologia<br />

Cveulebriv paranazaluri sinusebi steriluria. baqteriuli sinusitis<br />

ZiriTadi gamomwvevebia: Streptococus pneumonie; Haemophilus influenzae.<br />

am or gamomwvevze modis baqteriuli sinusitis <strong>da</strong>axloebiT 50%<br />

rogorc mozrdilebSi, ise bavSvTa asakSi. rogorc mozrdilebSi, ise<br />

bavSvebSi sinusitis 5%-s iwvevs Staphylococcus aureus, Staphylococcus pyogenes.<br />

bavSvebSi xSiria agreTve Moraxella catarrhalis (<strong>da</strong>axloebiT 20%),<br />

mozrdilebSi misi mizeziT gamowveuli sinusiti iSviaTia.<br />

mozrdilebSi sinusitis 10% gamowveulia anaerobuli baqteriebiT<br />

(Bacteroides spp, Porphyromonas spp, Peptosostreptococus spp). am floriT gamowveuli<br />

sinusiti xSir SemTxvevaSi asocirebulia kbilis <strong>da</strong>zianebasTan.<br />

Zalze iSviaTad (

stagnacias, pH-is <strong>da</strong> Jangbadis koncentraciis <strong>da</strong>qveiTebas, rac saukeTeso<br />

pirobas qmnis baqteriis cxovelmyofelobisTvis.<br />

sinusiti viTardeba nebismier asakSi. maqsilaruli (haimoris) <strong>da</strong><br />

ZiriTadi Zvlis wiaRi Cvil bavSvebsac aqvs ganviTarebuli, Tumca mcire<br />

zomisaa. Sublis Zvlis wiaRi viTardeba 5 wlis asaki<strong>da</strong>n <strong>da</strong> srulyofilad<br />

yalibdeba pubertatul periodSi. cxavis Zvlis wiaRi SesamCnevia 3 wli<strong>da</strong>n<br />

<strong>da</strong> srulyofilad viTardeba 12 wlis asakisaTvis.<br />

gamoyofen sinusitis ganviTarebis 5 xelSemwyob faqtors:<br />

janmrTelobis mdgomareoba (xSiri mri, alergiuli riniti,<br />

imunodeficiti <strong>da</strong> sxv);<br />

garemo gamRizianeblebi (Tambaqo, mavne gamonabolqvi, alergenebi);<br />

anatomiuri faqtori (adenoidebis hipertrofia, polipebi, Zgidis<br />

gamrudeba <strong>da</strong> sxv);<br />

medikamentebi (topiuri dekongestantebis xangrZlivi gamoyeneba);<br />

travma (kbilis eqstraqcia <strong>da</strong> sxv).<br />

klinikuri suraTi<br />

<strong>da</strong>avadebis diagnostika efuZneba <strong>da</strong>avadebis anamnezs, klinikuri<br />

suraTs, simptomebis xangrZlivobas, obieqtur gasinjvas <strong>da</strong>, saWiroebisas,<br />

rentgenologiuri gamokvlevis Sedegebs (mtkicebulebis done A).<br />

arc erTi klinikuri niSani <strong>da</strong>moukideblad ar aris mgrZnobiare <strong>da</strong><br />

specifiuri diagnozis <strong>da</strong>sasmelad.<br />

ba qteriuli sinusitis niSnebi<br />

bavSvebSi<br />

ba qteriuli sinusitis niSnebi<br />

mozrdilebSi<br />

13

• zemo sasunTqi gzebis infeqciis<br />

klinika, romelic ar<br />

umjobesdeba 10-14 dRis<br />

ganmavlobaSi <strong>da</strong> romelsac Tan<br />

axlavs 2 niSani:<br />

• cxviri<strong>da</strong>n Cirqovani gamonadeni<br />

<strong>da</strong><br />

• gaxangrZlivebuli ara<strong>da</strong>makmayofilebeli<br />

mdgomareoba<br />

+/_<br />

• cxeleba<br />

• xvela<br />

• agzneba<br />

• Zilianoba/leTargia<br />

• saxis tkivili<br />

mZime gamovlineba*<br />

mZime zogadi mdgomareoba:<br />

temperatura>39 0 (ar eqvemdebareba<br />

antipiretul saSualebebs)<br />

<strong>da</strong><br />

cxviri<strong>da</strong>n Cirqovani gamonadeni,<br />

romelic asocirebulia:<br />

• xvelasTan<br />

• Tavis tkivilTan<br />

• saxis SeSupebasTan<br />

• sinusis mgrZnobelobasTan.<br />

*Zlier iSviaTia bavSvebSi,<br />

miuTiTebs SesaZlo intrakraniuli<br />

garTulebebis arsebobaze.<br />

• zemo sasunTqi gzebis infeqciis<br />

klinika romelic ar umjobesdeba<br />

10-14 dRis ganmavlobaSi an<br />

uaresdeba 5 dRis Semdeg <strong>da</strong><br />

romelsac Tan axlavs 2 niSani:<br />

• cxviris blokireba /cxviri<strong>da</strong>n<br />

Cirqovani gamonadeni<br />

<strong>da</strong><br />

• saxis tkivili<br />

+/_<br />

• cxeleba<br />

• ybis Zvlisa <strong>da</strong> kbilis tkivili<br />

• saxis SeSupeba<br />

sxva SesaZlo NniSnebia:<br />

• Tavis tkivili<br />

• hiposmia/anosmia<br />

• yuris tkivili/wnevis <strong>da</strong><br />

<strong>da</strong>gubebis SegrZneba<br />

• gulisreva<br />

• xvela<br />

• saxis tkivili, romelic<br />

matuloba win <strong>da</strong>xrisas.<br />

mwvave siniusitis diagnozis saukeTeso simptomia sami ZiriTadi (ybis<br />

Zvlis <strong>da</strong> kbilis tkivili, topiuri dekongesantebis uefeqtoba <strong>da</strong><br />

cxviri<strong>da</strong>n Seferili gamonadenis arseboba) <strong>da</strong> 2 <strong>da</strong>matebiTi niSani<br />

(Cirqovani gamonadeni cxviri<strong>da</strong>n <strong>da</strong> cvlilebebi transiluminaciiT)<br />

(mtkicebulebis done A).<br />

mwvave sinusitis diagnozi SesaZlebelia gamoiricxos, Tu saxezea<br />

mocemuli niSnebi<strong>da</strong>n 2-ze naklebi. Tu saxezea 2 an 3 niSani<br />

diagnostikisaTvis SesaZlebelia saWiro iyos cxviris <strong>da</strong>namati Rruebis<br />

rentgenologiuri kvleva. Tu saxezea 4 niSani, maSin mwvave sinusitis<br />

diagnozis sarwmunoeba maRalia.<br />

klinikuri suraTi mozrdilebSi<br />

mwvave rinosinusiti ganisazRvreba <strong>da</strong>maxasiaTebeli simptomebiT,<br />

romelTa xangrZlivoba 4 kviraze naklebia. mwvave baqteriuli sinusiti<br />

Cveulebriv warmoadgens meorad infeqcias, rac sinusis RerZis<br />

14

obstruqciis, lorwos gasufTavebis meqanizmis <strong>da</strong>rRvevis (an orives<br />

erTad) Sedegs warmoadgens. epidemiologiuri monacemebis mixedviT,<br />

mozrdilebSi ze<strong>da</strong> sasunTqi gzebis infeqcias mxolod 0,2-<strong>da</strong>n 2%-Si<br />

rTuldeba baqteriuli rinosinusitiT. baqteriuli rinosinusitis<br />

diagnostirebis oqros stan<strong>da</strong>rts warmoadgens sinusis punqcia. S.<br />

Pneumoniae <strong>da</strong> Haemopilus influenzae is ZiriTadi baqteriebia, romlebic<br />

gamoiyofa inficirebuli maqsilaruli sinusi<strong>da</strong>n. Mmwvave baqteriuli<br />

sinusitis <strong>da</strong> ze<strong>da</strong> sasunTqi gzebis prolongirebuli virusuli infeqcias<br />

simptomatika Zalian msgavsia, ris gamoc xSirad xdeba virusuli<br />

paTologiis SecdomiT klasificireba.<br />

diagnostika bavSvebSi.<br />

sinusitis diagnostika ar un<strong>da</strong> <strong>da</strong>efuZnos mxolod gamonadenis<br />

xasiaTs, vinai<strong>da</strong>n lorwovan-Cirqovani gamonadeni SesaZlebelia<br />

aRiniSnebodes zemo sasunTqi gzebis virusuli infeqciebis drosac.<br />

Cveulebriv zemo sasunTqi gzebis virusuli infeqcia 5-7 dRis<br />

ganmavlobaSi grZeldeba. iSviaTad igi SeiZleba gaxangrZlivdes 10<br />

dRemdec, magram aseT dros yvela SemTxvevaSi saxezea klinikuri<br />

simptomebis gaumjobeseba. amitom mri-s simptomTa persistireba 10 dReze<br />

metad, rodesac ar aris gamoxatuli klinikuri gaumjobeseba,<br />

SesaZlebelia miuTiTebdes meora<strong>da</strong>d baqteriuli infeqciis Tan<strong>da</strong>rTvaze<br />

sinusitis saxiT.<br />

ZiriTadi simptomebi, romelsac efuZneba diagnozi:<br />

zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba<br />

10-14 dRis ganmavlobaSi;<br />

cxviriT sunTqvis blokireba/cxviri<strong>da</strong>n gamonadeni (SeiZleba mxolod<br />

lorwovani, Sesqelebuli, lorwovan Cirqovani);<br />

persistuli xvela, romelic Zlierdeba RamiT.<br />

Se<strong>da</strong>rebiT iSviaTad vlindeba gulisreva, yuris <strong>da</strong> yelis tkivili,<br />

saxis tkivili, SeSupeba.<br />

sinusitze eWvis SemTxvevaSi obieqturi gasinjvis dros un<strong>da</strong> Sefasdes:<br />

s a x e<br />

• Sesieba an eriTema <strong>da</strong>zianebis areSi;<br />

• mgrZnobeloba sinusis palpaciis an perkusiis dros.<br />

palpaciisas mcire asakis bavSvebSi saxis tkivili <strong>da</strong> sinusis<br />

mgrZnobeloba ar vlindeba, Tumca es simptomebi kargi indikatoria<br />

saskolo asakis bavSvebsa <strong>da</strong> mozrdilebSi. ze<strong>da</strong> ybis Zvlisa <strong>da</strong> Sublis<br />

Zvlis perkusiis an zewolis dros gamoxatuli erTi mxaris tkivili<br />

miuTiTebs baqteriuli sinusitis arsebobaze.<br />

15

T v a l e b i<br />

• periorbitaluri Sesieba<br />

c x v i r i<br />

• lorwovan-Cirqovani sekretis arseboba;<br />

• cxviris lorwovani garsis eriTema an SeSupeba;<br />

• anatomiuri anomaliebi (Zgidis gamrudeba);<br />

• ucxo sxeulis arseboba.<br />

p i r i d a x a x a<br />

• cxviris ukana Camonadeni;<br />

• ZiriTadi kbilebis mgrZnobeloba.<br />

y u r i<br />

• Tanmxlebi Sua yuris anTeba bavSvebSi.<br />

k i s e r i<br />

• limfadenopaTia.<br />

diagnostika mozrdilebSi<br />

aucilebelia baqteriuli <strong>da</strong> virusuli rinosinusitis Se<strong>da</strong>reba <strong>da</strong><br />

zusti diagnostireba. ganxilvis sagania im specifiuri niSnebis simcire,<br />

romelic gamijnavs baqteriul rinosinusits ze<strong>da</strong> <strong>respiraciuli</strong> traqtis<br />

arabaqteriuli infeqciisagan. xSirad pacientebsa <strong>da</strong> eqimebs swamT, rom<br />

ze<strong>da</strong> sasunTqi gzebis infeqcia grZeldeba sakmaod xangrZlivad, amitom<br />

antibiotikoTerapia aucilebelia. baqteriuli rinosinusiti ar aris<br />

<strong>da</strong>maxasiaTebeli im pacientebSi, romelTac simptomebi ugrZeldebaT 7<br />

dReze naklebi drois manZilze. miuxe<strong>da</strong>vad amisa, 7 dReze meti drois<br />

manZilze simptomebis arsebobac baqteriuli rinosinusitis arsebobis<br />

araspecifiuri mimaniSnebelia. Cirqovani gamonadeni cxviri<strong>da</strong>n,<br />

maqsilaruli kbilebis gaswvriv tkivili an facialuri tkivili,<br />

unilateraluri sinusis mgrZnobeloba <strong>da</strong> sawyisi gaumjobesebis Semdeg<br />

avadobis simptomTa gauareseba miiCneva baqteriuli genezis rinosinusitis<br />

mimaniSnebel <strong>da</strong>mxmare niSnebad.<br />

diagnostika<br />

sawyis etapze sinusitze saeWvo SemTxvevebSi rutinuli<br />

rentgenologiuri kvleva ar aris saWiro. ar aris rekomendebuli<br />

sinusebis rentgenografiis Catareba 6 wlamde asakSic. miRebulia, rom<br />

sinusitis mkurnaloba SesaZlebelia <strong>da</strong>iwyos mxolod klinikur suraTze<br />

<strong>da</strong>yrdnobiT <strong>da</strong>matebiTi rentgenologiuri kvlevebis Catarebis gareSe.<br />

pir<strong>da</strong>piri rentgenografia ar gamoirCeva maRali mgrZnobelobiT <strong>da</strong><br />

mxolod 54% SemTxvevaSi gvaZlevs sinusitis diagnostikis saSualebas<br />

16

(mtkicebulebis done A). sinusitis diagnostikisaTvis gamoiyeneba Semdegi<br />

rentgenologiuri proeqciebi: Wate-is proeqcia - ZiriTa<strong>da</strong>d fasdeba<br />

haimoris Rruebis mdgomareoba. Caldwell-is proeqcia - ZiriTa<strong>da</strong>d fasdeba<br />

eTmoiduri <strong>da</strong> Sublis wiaRi. Submentovertex-is proeqcia - ZiriTa<strong>da</strong>d fasdeba<br />

ZiriTadi Zvlis <strong>da</strong> cxavis Zvlis sinusi.<br />

yvela SemTxvevaSi rentgenografia un<strong>da</strong> Catardes pacientis<br />

vertikalur poziciaSi, raTa rentgenogramaze Sefasdes sinusSi haerisiTxis<br />

done.<br />

rentgenologiuri kvlevis Catareba saWiroa Semdeg SemTxvevebSi:<br />

mwvave sinusitis diagnozis dros, Tu saeWvoa subperiostuli an<br />

orbitaluri abscesi;<br />

mwvave sinusitis diagnozis dros, Tu saeWvoa intrakraniuli<br />

garTulebebi;<br />

Tu mkurnalobis miuxe<strong>da</strong>vad ar aris gaumjobeseba <strong>da</strong> saWiroa<br />

diagnozis <strong>da</strong><strong>da</strong>stureba.<br />

sinusebis ultrasonografiuli kvleva ar gamoirCeva maRali<br />

mgrZnobelobiTa <strong>da</strong> specifiurobiT <strong>da</strong> ar aris rekomendebuli<br />

(mtkicebulebis done D).<br />

kompiuteruli tomografia ufro maRalmgrZnobiarea, vidre<br />

rentgenologiuri gamokvleva. misi gamoyeneba naCvenebia, Tu saeWvoa<br />

cxviris <strong>da</strong>namati Rruebis avTvisebiani paTologia (mtkicebulebis done A).<br />

misi gamoyeneba agreTve rekomendebulia im pacientebSi, romelTac<br />

esaWiroebaT sinusitis qirurgiuli mkurnaloba (mtkicebulebis done B).<br />

kompiuteruli tomografiis gamoyeneba agreTve mizanSewonilia:<br />

sinusitis garTulebebis ganviTarebis SemTxvevaSi;<br />

qronikuli sinusitis dros, romelic ar eqvemdebareba mkurnalobas;<br />

<strong>da</strong>avadebis mZime mimdinareobis SemTxvevaSi, rodesac diagnozi saeWvoa.<br />

birTvul-magnituri rezonansuli gamokvleva (MRI) ar aris rutinulad<br />

rekomendebuli sinusitis <strong>da</strong>ignostikisaTvis.<br />

laboratoriuli kvleva<br />

gaurTulebeli mwvave sinusitis dros sisxlis saerTo analizis an<br />

nazofaringiuli kulturis rutinulad Catareba ar aris rekomendebuli.<br />

<strong>da</strong>dgenilia, rom nazofaringiuli Camonarecxis an yelis nacxiT miRebuli<br />

kultura ar Seesabameba sinusis aspiraciiT miRebul Stamebs.<br />

sinusis aspiracia <strong>da</strong> baqteriuli kultura iTvleba baqteriuli<br />

sinusitis diagnostikis “oqros stan<strong>da</strong>rtad”. misi gamoyeneba ar aris<br />

17

saWiro gaurTulebel SemTxvevebSi sinusitis sawyisi mkurnalobis<br />

gansazRvrisaTvis. Rrus pir<strong>da</strong>piri punqcia <strong>da</strong> aspiracia naCvenebia, Tu:<br />

<strong>da</strong>avadeba mZimed mimdinareobs;<br />

imunodeficituri mdgomareobis dros;<br />

intrakranialuri garTulebebis SemTxvevaSi.<br />

mkurnaloba<br />

kvlevebi a<strong>da</strong>stureben, rom sinusiti uxSiresad virusuli genezisaa <strong>da</strong><br />

60% SemTxvevaSi spontanurad gaivlis antibiotikoTerapiiis gareSe.<br />

baqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis<br />

drenireba <strong>da</strong> paTologiuri baqteriebis zrdis Seferxeba. bavSvebSi<br />

baqteriuli sinusitis samkurnalod naCvenebia antibiotikoTerapia<br />

(mtkicebulebis done A).<br />

antibiotikoTerapia<br />

baqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis<br />

drenireba <strong>da</strong> paTologiuri baqteriebis zrdis Seferxeba. mwvave sinusitis<br />

samkurnalod antibiotikoTerapiis <strong>da</strong>wyebis Cvenebas, rogorc<br />

mozrdilebSi, ise bavSvebSi warmoadgens Semdegi klinikuri simtomatikis<br />

arseboba:<br />

• simptomebis persistireba (magaliTad, Tu klinikuri niSnebi<br />

grZeldeba 7 - 10 dReze meti);<br />

• mZime simptomatika (mag: profuzuli Cirqovani gamonadeni cxviri<strong>da</strong>n,<br />

saxis tkivili <strong>da</strong> sistemuri <strong>da</strong>zianebis niSnebi);<br />

• pacientis mdgomareobis <strong>da</strong> simptomebis gauareseba.<br />

mozrdilebSi randomizirebuli, ormagi brma, placebokontrolirebadi<br />

kvlevebiT mwvave baqteriuli rinosinusitis<br />

mkurnalobamde <strong>da</strong> mkurnalobis Semdeg miRebuli sinusis aspiratis<br />

kulturis monacemebi ar a<strong>da</strong>sturebs antibiotikoTerapiis gamoyenebis<br />

saWiroebas. mwvave rinosinusitis dros xuT randomizirebul, ormag-brma<br />

klinikur kvlevebSi antibiotikebiT mkurnaloba Se<strong>da</strong>rebul iqna<br />

placebosTan. Tumca antibiotikebi ufro efeqturia, vidre placebo,<br />

simptomebis Semcirebis TvalTaxedviT efeqtis sidide (sarwmunoebis<br />

xarisxi) Se<strong>da</strong>rebiT <strong>da</strong>balia. ufro metic, pacientTa umravlesobis<br />

mdgomareoba, romlebic Rebuloben placebos, gaumjobes<strong>da</strong><br />

antibiotikoTerapiis gareSec.<br />

antibiotikoTerapiis <strong>da</strong>niSvnisas SeiZleba gamoyenebuli iyos “moicade<br />

<strong>da</strong> Seafase”–s principi, roca eqimi pacients ganmeorebiT vizitze ibarebs.<br />

18

aseT dros antibiotiki iniSneba, Tu pacientis mdgomareoba uaresdeba an<br />

vlindeba simptomebis persistireba.<br />

ar arsebobs mkacri mtkicebulebebi romelime antibiotikis gamoyenebis<br />

sasargeblod. antibiotikis SerCevis kriteriumebi efuZneba <strong>da</strong>avadebis<br />

klinikas, uxSiresi gamomwvevi floris gansazRvras, xarjTefeqturobas,<br />

gverdiTi movlenebis Sefasebas.<br />

pirveli rigis preparats, rogorc bavSvebSi, ise mozrdilebSi<br />

miekuTvneba amoqsicilini (rekomen<strong>da</strong>cia A). misi efeqturoba<br />

<strong>da</strong><strong>da</strong>sturebulia placebo-kontrolirebadi kvlevebiT. farmakokinetikuri<br />

Tvisebebi<strong>da</strong>n gamomdinare igi maRali koncentraciiT grovdeba rbil<br />

qsovilebSi <strong>da</strong> sinusitis gamomwvev yvela mikroorganizmis mimarT maRali<br />

aqtivoba gaaCnia, kargad aiTviseba mosaxleobis didi nawilis mier <strong>da</strong> ar<br />

aris ZviradRirebuli.<br />

mozrdilebSi, Tu penicilinebis jgufis antibiotikebis mimarT<br />

arsebobs alergiuli anamnezi, SesaZlebelia <strong>da</strong>iniSnos doqsiciklini,<br />

romelic aseve kargad aiTviseba, efeqturia sinusitis samkurnalod <strong>da</strong><br />

advilad misaRebia. bavSvTa asakSi is ar gamoiyeneba.<br />

penicilinebze alergiis SemTxvvaSi, rogorc bavSvebSi, iseve<br />

mozrdilebSi SeiZleba <strong>da</strong>iniSnos azitromicini <strong>da</strong> klaritromicini,<br />

SesaZlebelia cefalosporinebis gamoyenebac (rekomen<strong>da</strong>cia A).<br />

antibiotikoTerapiis xangrZlivobaa 10 an 14 dRe, gar<strong>da</strong> im<br />

SemTxvevebisa, rodesac gamoiyeneba azitromicini.<br />

Tu sawyisi 10-14-dRiani mkurnalobis Semdeg mdgomareoba nawilobriv<br />

gaumjobes<strong>da</strong>, antibiotikoTarapia un<strong>da</strong> gagrZeldes kidev 7 dRis<br />

ganmavlobaSi (rekomen<strong>da</strong>cia C).<br />

Tu sawyisi 10-14-dRiani mkurnalobis Semdeg mdgomareoba minimalurad<br />

gaumjobes<strong>da</strong> an saerTod uefeqtoa, un<strong>da</strong> <strong>da</strong>iniSnos farTo speqtris<br />

antibiotiki: amoqsicilin-klavulanati, cefalosporini an<br />

levofloqsacini (mozrdilebSi).<br />

Tu pacients ar mkurnaloben antibiotikiT, igi un<strong>da</strong> <strong>da</strong>ibaron 7 dRis<br />

Semdeg, raTa <strong>da</strong>dgindes, xom ar gauares<strong>da</strong> simptomatika an mox<strong>da</strong> Tu ara<br />

gaumjobeseba.<br />

Tu pacients mkurnaloben antibiotikebiT <strong>da</strong> misi mdomareoba ar<br />

umjobesdeba, an Tu ver xerxdeba antibiotikis miReba, magaliTad Rebinebis<br />

SemTxvevaSi, ganmeorebiTi viziti saWiroa Catardes 72 saaTSi.<br />

Tu simptomatika grZeldeba <strong>da</strong> ar umjobesdeba Sesabamisi<br />

antibiotikoTerapiis <strong>da</strong>sasruls, saWiroa:<br />

• ganmeorebiT ga<strong>da</strong>isinjos diagnozi;<br />

19

• Sefasdes garTulebebis arseboba;<br />

• Sefasdes, Tu ramdenad asrulebs pacienti eqimis <strong>da</strong>niSnulebas.<br />

Tu pacienti sworad ar asrulebs eqimis <strong>da</strong>niSnulebas:P<br />

• SeiZleba gagrZeldes mocemuli antibiotiki;<br />

• Tu antibiotikze aRiniSneba Rebineba, igi un<strong>da</strong> Seicvalos pirveli<br />

rigis sxva preparatiT, an <strong>da</strong>iniSnos saineqcio antibiotiki, sanam<br />

ar moxdeba Rebinebis kupireba, ris Semdegac kvlav xdeba<br />

ga<strong>da</strong>svla oralur antibiotikze.<br />

Tu pacienti sworad asrulebs eqimis <strong>da</strong>niSnulebas:<br />

• saWiroa meore rigis antibiotikebis gamoyeneba.<br />

meore rigis preparatebs miekuTvneba:<br />

• im pirebSi, romelTac ar aqvT alergia penicilinze<br />

amoqsicilinis <strong>da</strong> klavulonis mJavis kombinirebuli preparati<br />

efeqturia im baqteriebis sawinaaRmdegod romelic iwvevs<br />

sinusits, maT Soris Moraxella catharalis, Streptococus pneumonie-is<br />

penicilin-rezistentuli Stamebis mimarT.<br />

• II Taobis cefalosporinebi.<br />

Tu saeWvoa anaerobuli baqteriebiT gamowveuli sinusiti<br />

SesaZlebelia mkurnalobaSi gamoyenebuli iqnas metroni<strong>da</strong>zoli.<br />

Tu antibiotikis meore kursis Semdeg pacientis mdgomareoba ar<br />

umjobesdeba, mizanSewonilia sinusis punqcia <strong>da</strong> aspirati<strong>da</strong>n kulturis<br />

mgrZnobelobis gansazRvra.<br />

orsul qalebTan <strong>da</strong> meZuZur dedebTan gamoiyeneba eriTromicini.<br />

miuxe<strong>da</strong>vad imisa, rom klaritromicinTan <strong>da</strong> azitromicinTan Se<strong>da</strong>rebiT is<br />

metad aRizianebs kuW-nawlavis traqts <strong>da</strong> Haemophilus influenzae–ze naklebad<br />

moqmedebs, <strong>da</strong>dgenilia eriTromicinis usafrTxoeba orsulebSi.<br />

ana lgetiuri <strong>da</strong> an tipiretuli saSualebebi<br />

mwvave sinusitis mqone pacientebSi, romelTac gamoxatuli aqvT<br />

tkivilis sindromi, iniSneba antipiretuli preparatebi tkivilisa <strong>da</strong><br />

temperaturuli reaqciis kupirebis mizniT. rogorc bavSvebSi, ise<br />

mozrdilebSi naCvenebia paracetamolis an iboprufenis gamoyeneba.<br />

antibiotikebi <strong>da</strong> analgetikebi Cveulebriv sakmarisia sinusitis<br />

samkurnalod. Tumca SesaZlebelia iSviaT SemTxvevaSi <strong>da</strong>matebiT<br />

gamoyenebuli iqnas preparatebi, romlebic amcireben lorwovanis<br />

SeSupebas, aumjobeseben sinusis drenaJs.<br />

dekongestantebi<br />

intranazaluri dekongestantebis gamoyeneba moklevadiani kursiT<br />

SesaZlebelia sinusitis samkurnalod (mtkicebuleba C), Tumca maTi<br />

20

gamoyenebis sasargeblod mxolod mcire raodenobiT mtkicebulebebi<br />

arsebobs. dekongestantebi xels uwyoben lorwovani garsis SeSupebis<br />

Semcirebas <strong>da</strong> mukociliarul klirenss. intranazaluri dekongestantebis<br />

xangrZlivi droiT gamoyeneba ar aris rekomendebuli (ara umetes 7 dRisa).<br />

intranazaluri steroidebi<br />

intranazaluri steroidebi mwvave sinusitis samkurnalod rutinulad<br />

naCvenebi ar aris, Tumca SeiZleba misi, rogorc <strong>da</strong>mxmare saSualebis,<br />

gamoyeneba (mtkicebuleba A). intranazaluri steroidebi amcirebs<br />

lorwovanis SeSupebas, Tumca maTi efeqti vlindeba mxolod 1 kviris<br />

Semdeg, ris gamoc misi gamoyeneba mwvave sinusitis samkurnalod ar aris<br />

mizanSewonili. topikuri steroidebi naCvnebia qronikuli sinusitis dros.<br />

oraluri <strong>da</strong> intranazaluri an tihistaminuri preparatebi<br />

antihistaminuri preparatebi ar aris naCvenebi (mtkicebuleba C), isini<br />

iwveven lorwovani garsis simSrales, sekretis Sesqelebas, rac aqveiTebs<br />

sinusis drenaJis SesaZleblobas.<br />

mukolitikebi<br />

ar aris rekomendebuli, vinai<strong>da</strong>n ar aris <strong>da</strong><strong>da</strong>sturebuli maTi<br />

efeqturoba.<br />

sxva saSualebebi<br />

ar arsebobs klinikuri mtkicebulebebi fiziologiuri xsnaris<br />

nazaluri gamoyenebis Sesaxeb. Tumca SesaZlebelia fiziologiuri xsnaris<br />

gamoyenebam xeli SeuSalos fufxebis warmoqmas <strong>da</strong> gaaTxelos sekreti,<br />

rac gaaiolebs mis drenaJs. <strong>da</strong>matebiT fiziologiurma xsnarma<br />

SesaZlebelia imoqmedos cxviris lorwovan garsze, rogorc sustma<br />

vazokonstriqtorma.<br />

ar arsebobs mtkicebulebebi sinusis drenaJis gaumjobesebis mizniT<br />

cxeli orTqlis gamoyenebis Sesaxeb. cxeli orTqlis inhalaciis<br />

gamoyeneba ar aris mizanSewonili, man SesaZlebelia gamoiwvios <strong>da</strong>mwvroba,<br />

gansakuTrebiT bavSvebSi. SeiZleba gamoyenebuli iyos abazanaSi cxeli<br />

wylis moSvebisas warmoqmnili orTqli.<br />

referalis Cvenebebia:<br />

1. sinusitis garTulebebi:<br />

a. orbitaluri:<br />

orbitaluri celuliti.<br />

b. lokaluri:<br />

mukocele an mukopiocele.<br />

c. intrakranialuri<br />

• baqteriuli meningiti;<br />

• cerebruli abscesi;<br />

21

• epiduraluri abscesi;<br />

• osteomieliti <strong>da</strong> sxv.<br />

2. meore rigis preparatebiT mkurnalobis araefeqturoba;<br />

3. rekurentuli <strong>da</strong>avadeba (3 epizodze meti weliwadSi);<br />

4. bavSvebSi zemo sasunTqi gzebis Tan<strong>da</strong>yolili anatomiuri anomalia<br />

Tu saeWvoa baqteriuli sinusitis garTuleba, aucilebelia<br />

ofTalmologis, infeqcionistis, neiroqirurgis konsultacia. aseT<br />

SemTxvevaSi xSirad saWiroa agresiuli mkurnaloba.<br />

mw va ve ot iti<br />

gaidlainis au cilebloba<br />

mwvave otiti zemo sasunTqi gzebis <strong>da</strong>zianebis erT-erT umTavres<br />

mizezs warmoadgens. is aseve erT-erT uxSiresi mizezia aSS-Si<br />

antibiotikebis <strong>da</strong>niSvnis mixedviT. aqe<strong>da</strong>n gamomdinare, mwvave otitis<br />

adeqvatur marTvas SeuZlia mniSvnelovani gavlena moaxdinos a<strong>da</strong>mianis<br />

janmrTelobaze, mkurnalobis Rirebulebasa <strong>da</strong> antibiotikebis <strong>da</strong>niSvnis<br />

sixSireze. mwvave otiti aseve mniSvnelovani socialuri tvirTia<br />

samsaxuris <strong>da</strong> skolis gacdenis TvalsazrisiT. otitis mkurnalobis<br />

pir<strong>da</strong>piri QRirebuleba erTi wlis ganmavlobaSi aSS-Si 1,96 mlrd<br />

dolaria, xolo arapir<strong>da</strong>piri – 1,02 mlrd. amave qveyanaSi otitis gamo<br />

eqimTan vizitis 1000 SemTxvevaSi 809 avadmyofTan antibaqteriuli<br />

preparati iqna <strong>da</strong>niSnuli.<br />

visTvis aris gankuTvnili gaidlaini<br />

22

pediatri;<br />

zogadi praqtikis eqimi;<br />

ga<strong>da</strong>udebeli samedicino <strong>da</strong>xmarebis eqimi;<br />

yel-yur-cxviris eqimi.<br />

CarTvis kriteriumebi:<br />

pacientebi, romelTac aReniSnebaT Sua yuris mwvave anTebis niSnebi<br />

(mwvave otiti).<br />

gamoricxvis kriteriumebi<br />

pacientebi Tanmxlebi mdgomareobiT, romlebic zrdian anTebis<br />

Camoyalibebis risks: imunodeficiti, nevrologiuri problemebi,<br />

sensoruli deficitebi.<br />

definicia<br />

otiti Sua yuris anTebiTi <strong>da</strong>avadebis saerTo saxelia, romelsac aqvs<br />

mwvave an qronikuli xasiaTi, mimdinareobs simptomebiT an maT gareSe, <strong>da</strong><br />

romelsac iwvevs virusi an baqteria. marTvis gansxvavebuli strategiebi<br />

ganapirobeben mis gansxvavebul klinikur klasifikacias: mwvave Sua yuris<br />

anTeba an Sua yuris anTeba gamonadeniT. ar arsebobs otitis SeTanxmebuli<br />

definicia. samuSao definiciad mowodebulia Sua yuris anTeba swrafi<br />

ganviTarebiT adgilobrivi (yuris tkivili) <strong>da</strong> zogadi simptomatikiT<br />

(cxeleba, gaRizianeba, cudi Zili). SesaZlebelia adgili hqondes ze<strong>da</strong><br />

sasunTqi gzebis <strong>da</strong>avadebisTvis <strong>da</strong>maxasiaTebel simptomebs: xvelas <strong>da</strong><br />

rinoreas. zoga<strong>da</strong>d SeiZleba iTqvas, rom mwvave otitis diagnozi moiTxovs:<br />

<strong>da</strong>avadebis simptomebis ganviTarebis mwvave <strong>da</strong>sawyiss; gamonadenis<br />

arsebobas Sua yurSi (timpanuri membranis SeSupeba, timpanuri membranis<br />

mobilurobis SezRudva an ararseboba, otorea); Sua yuris anTebis niSnebis<br />

<strong>da</strong> simptomebis arsebobas (timpanuri membranis hiperemia, otalgia).<br />

Sua yuris anTeba gamonadeniT ganmartebulia, rogorc Sua yuris<br />

anTeba, romelsac Tan sdevs Sua yurSi siTxis <strong>da</strong>groveba <strong>da</strong> ar sdevs<br />

mwvave anTebis niSnebi. Sua yuris anTeba gamonadeniT xSirad asimptomuria<br />

<strong>da</strong> misTvis tkivili ar aris <strong>da</strong>maxasiaTebeli.<br />

otitis<br />

saxeoba<br />

siTxe Sua yurSi<br />

MEE<br />

miringiti (<strong>da</strong>fis<br />

apkis anTeba)<br />

def inicia<br />

siTxe Sua yurSi, miuxe<strong>da</strong>vad<br />

warmoSobisa<br />

<strong>da</strong>fis apkis eriTema gamonadenis<br />

gareSe (SesaZlebelia bavSvis<br />

tirilis dros adgili hqondes<br />

cru Sedegs)<br />

Se niSvna<br />

SesaZloa nanaxi iyos<br />

otoskopiiT<br />

uxSiresad virusuli<br />

etiologiis.<br />

ar reagirebs<br />

antibiotikebze.<br />

adreuli etapi mwvave<br />

23

Sua yuris mwvave<br />

anTeba<br />

sporaduli<br />

xasiaTis mwvave<br />

Sua yuris anTeba<br />

morecidive mwvave<br />

Sua yuris anTeba<br />

Sua yuris anTeba<br />

gamonadeniT<br />

qronikuli Sua<br />

yuris anTeba<br />

gamonadeniT<br />

siTxis arseboba Sua yurSi<br />

mwvave <strong>da</strong>sawyisiT: tkiviliT,<br />

otoreiT, cxelebiT,<br />

anoreqsiiT, RebinebiT an/<strong>da</strong><br />

sxva simptomebiT<br />

mwvave anTeba, romelic 3 Tvis<br />

Semdeg ganviTar<strong>da</strong> ga<strong>da</strong>tanili<br />

epizodis Semdeg.<br />

6 epizodi 12 Tvis ganmavloba-<br />

Si. gaTvaliswinebuli un<strong>da</strong><br />

iyos epizodebis simZime <strong>da</strong><br />

gamonadenis arseboba<br />

siTxe Sua yurSi anTebis<br />

niSnebis gareSe<br />

mimdinareobs 3 Tveze metxans.<br />

anTebis an procesis<br />

CaTavebisas.<br />

pediatrebis uxSiresi<br />

diagnozi: 48% - 6<br />

Tvemde asakSi, 79%- 1<br />

wlamde asakSi <strong>da</strong> 90%<br />

2 wlamde asakSi<br />

(Paradise 1997 [C])<br />

Sea<strong>da</strong>reT morecidive<br />

mwvave Sua yuris<br />

anTebas.<br />

aReniSnebaT 15-30%-Si<br />

gavrceleba bavSvebSi<br />

aris 15%. axlavs<br />

mwvave anTeba.<br />

epidemiologia<br />

aTi wlis asakis bavSvebis <strong>da</strong>axloebiT 75% ze<strong>da</strong> sasunTqi gzebis<br />

<strong><strong>da</strong>avadebebi</strong>sas avlenen Sua yuris anTebas. oTxi<strong>da</strong>n erTi bavSvi pirveli<br />

aTi wlis manZilze erTxel mainc avadobs otitiT. <strong>da</strong>avadebis piki<br />

gvxvdeba 3-6 wlis asakSi. kvlevebi a<strong>da</strong>stureben, rom oTx wlamde asakSi<br />

bavSvTaA 80%-s erTxel mainc hqon<strong>da</strong> otiti gamonadeniT <strong>da</strong> webvadi<br />

sacobiT yurSi. mwvave otiti Se<strong>da</strong>rebiT iSviaTia mozrdilebSi, otitis<br />

SemTxvevaTa 2/3 aRiniSneba 10 wlamde asakis bavSvebSi.<br />

etiologia<br />

mwvave otitis gamomwvevi uxSiresi baqteriuli agentebia S.pneumonie,<br />

H.influenzae <strong>da</strong> M.cattarhalis. mwvave otitis aseve xSiri mizezia virusi (40%):<br />

rsv, paragripis virusi <strong>da</strong> gripis virusebi. isini virusuli otitebis 81%-<br />

s Seadgenen (rekomen<strong>da</strong>cia C). virusul-baqteriul asociaciebs Sua yurSi<br />

procesis gaxangrZlivebasTan <strong>da</strong> <strong>da</strong>gvianebul baqteriul klirensTan<br />

mivyevarT.<br />

risk-faqtorebi<br />

asaki < 2 welze;<br />

ojaxis wevrebis avadoba <strong>respiraciuli</strong> infeqciebiT;<br />

mSoblebis mier Tambaqos moxmareba;<br />

ZuZuTi kvebis xangrZlivoba < 3 Tvemde;<br />

memkvidruli ganwyoba.<br />

24

klinikuri suraTi<br />

Sua yuris anTebis uxSiresi simptomebia: tkivili, cxeleba,<br />

gaRizianebadoba, otorea (gamonadeni yuri<strong>da</strong>n), leTargia, anoreqsia <strong>da</strong><br />

Rebineba. specifiuri niSnebis nakleboba, gansakuTrebiT or wlamde asakSi,<br />

arTulebs Sua yuris mwvave anTebis dignozis <strong>da</strong>dgenas.<br />

Sua yuris anTeba gamonadeniT SesaZloa saerTod simptomebis gareSe<br />

mimdinareobdes <strong>da</strong> gamovlenil iyos mxolod urTierTobis, qcevis,<br />

swavlis <strong>da</strong> metyvelebis problemebiT.<br />

g a s i n j v i s t e q n i k a .<br />

Sua yuris paTologiis diagnostireba <strong>da</strong>, gansakuTrebiT misi gamijvna<br />

klinikuri mimdinareobis mixedviT ar aris advili. kargad trenirebuli<br />

specialistis mier otoskopiiT Sua yuris areSi siTxis arsebobis<br />

<strong>da</strong>dgenis mgrZnobeloba 90%-ia, specifiuroba 80%. cxadia, am maCveneblebis<br />

miRweva SeuZlebelia, Tu specialisti, romelic sinjavs bavSvs, ar aris<br />

sakmarisad gamocdili. gansakuTrebiT maRalia pnevmo-otoskopiiT<br />

<strong>da</strong>dgenili diagnozis specifiuroba <strong>da</strong> mgrZnobeloba. CvenTan es meTodi<br />

<strong>pirveladi</strong> <strong>jan<strong>da</strong>cvis</strong> rgolSi zogadi praqtikis eqimebis mier ar aris<br />

farTod gamoyenebuli.<br />

a n a m n e z i<br />

mwvave otitis <strong>da</strong>sadgenad un<strong>da</strong> aRiniSnebodes simptomebis mwvave<br />

<strong>da</strong>sawyisi, Sua yurSi gamonadeni, Sua yuris anTebis niSnebi (sarwmunoebis<br />

done II).<br />

mwvave otitis diagnostika<br />

1. simtomatikis swrafi Camoyalibeba<br />

2.Sua yuri<strong>da</strong>n gamonadenis arseboba, razec miiuTiTebs erTi Semdegi<strong>da</strong>n:<br />

<br />

<br />

<br />

timpanuri memebranis SeSupeba <strong>da</strong> reliefis ar arseboba;<br />

membranis <strong>da</strong>qveiTebuli mobiluroba;<br />

TeTri an/<strong>da</strong> yviTeli nadebi membranaze;<br />

otorea<br />

3. Sua yuris anTebis simptomebi <strong>da</strong> niSnebi, razec miuTiTebs:<br />

<br />

<br />

wiTeli <strong>da</strong> SeSupebuli timpanuri membrana;<br />

tkivili anu otalgia ukanaskneli 24 saaTis manZilze.<br />

mwvave otitis diagnostikis sizustis gazrdis mizniT rekomendebulia<br />

otoskopis an/<strong>da</strong> timpanometriis gamoyeneba (sarwmunoebis done II).<br />

randomizebuli, kontrolirebadi kvlevebi a<strong>da</strong>stureben, rom<br />

timpanometriis gamoyeneba amcirebs otitis diagnozis sixSires 14-40%-iT.<br />

25

otalgia un<strong>da</strong> iyos Sefasebuli, rogorc diskomforti, romelic<br />

normalur aqtivobas an/<strong>da</strong> Zils uSlis xels.<br />

rekomendebulia pacientebSi morecidive mwvave otitiT<br />

gansakuTrebuli yuradReba <strong>da</strong>eTmos Civils smenis <strong>da</strong>qveiTebis, metyvelebis<br />

Seferxebis Sesaxeb.<br />

aucileblad un<strong>da</strong> iqnes gaTvaliswinebuli, rom otitisaTvis<br />

<strong>da</strong>maxasiaTebeli simptomebi <strong>da</strong> niSnebi SeiZleba gaqres membranis<br />

perforaciis Semdeg. gar<strong>da</strong> amisa, <strong>da</strong>avadebis ga<strong>da</strong>tanis Semdeg Sua yurSi<br />

gamonadeni SeiZleba <strong>da</strong>rCes mwvave otitis simptomebis gaqrobis Semdeg<br />

(sarwmunoebis done IV).<br />

<br />

<br />

im SemTxvevbSi, rodesac saeWvoa smenis <strong>da</strong>qveiTeba, aucilebelia<br />

specialistis konsultacia <strong>da</strong> audiometriis Catareba;<br />

Tu erTkviriani mkurnalobis fonze gaumjobeseba ar aRiniSneba,<br />

aucilebelia otolaringologis konsultacia;<br />

Tu mwvave Cirqovani otitis dros aRiniSneba gareTa sasmen milSi<br />

pulsirebadi Cirqovani gamonadeni, aucilebelia otolaringologis<br />

konsultacia;<br />

marTva<br />

bavSvebSi mwvave otitis msubuqi formis dros SemTxvevaTa <strong>da</strong>axloebiT<br />

80% mkurnalobis gareSe gamojanmrTelebiT mTavrdeba 3 dRis<br />

ganmavlobaSi. mwvave otitis recidivebi SeiZleba aRiniSnos uefeqto<br />

mkurnalobis an reinfeqciis gamo. mravali kvlevis miuxe<strong>da</strong>vad dReisaTvis<br />

ar arsebobs otitis mkurnalobis saerTaSoriso konsesunsi, gansakuTrebiT<br />

es exeba antibiotikebs.<br />

a n a l g e t i k e b i<br />

mwvave otitis marTvaSi un<strong>da</strong> iyos gaTvaliswinebuli tkivilis<br />

Sefaseba. tkivilis SemTxvevaSi aucilebelia analgetikebis gamoyeneba. es<br />

aris rekomen<strong>da</strong>cia, romelic eyrdnoba randomizirebul klinikur kvlevebs.<br />

xSir SemTxvevaSi eqimebi mas saTanado yuradRebas ar aqceven. tkivilis<br />

marTva, gansakuTrebiT <strong>da</strong>avadebis pirvel 24 saaTSi aucilebelia<br />

antibiotikoTerapiis miuxe<strong>da</strong>vad.<br />

sa xeoba<br />

acetaminofeni, ibuprofeni<br />

otalgiis mkurnaloba<br />

SeniSvna<br />

efeqturi saSualeba msubuqi <strong>da</strong><br />

saSualo siZlieris tkivilis dros,<br />

farTod xelmisawvdomia.<br />

Sinauri saSualebebi: cxeli<br />

safenebi, zeTi, marilis safenebi (ar<br />

arsebobs efeqturobis<br />

SesaZloa hqondes garkveuli<br />

efeqturoba<br />

26

<strong>da</strong>ma<strong>da</strong>sturebeli kontrolirebadi<br />

kvlevebi)<br />

topikuri saSualebebi<br />

benzokaini<br />

naturopaTiuri saSualebebi<br />

homeopatiuri saSualebebi<br />

narkotikuli analgetikebi (kodeini<br />

an misi analogebi)<br />

xanmokle efeqturoba<br />

ar asebobs kontrolirebadi<br />

kvlevebi<br />

efeqturia saSualo <strong>da</strong> Zlieri<br />

tkivilis dros, saWiroebs recepts,<br />

arsebobs sunTqvis <strong>da</strong>Trgunvis<br />

riski, cnobierebis Secvlis riski<br />

<br />

mwvave otitis dros tkivilis marTvaSi paracetamols upiratesoba<br />

un<strong>da</strong> mieniWos arasteroiduli anTebis sawinaaRmdego<br />

saSualebebTan Se<strong>da</strong>rebiT am ukanasknelis gverdiTi movlenebis<br />

gamo (sarwmunoebis done I). mSoblebs un<strong>da</strong> miewodoT informacia<br />

mosalodneli safrTxis Sesaxeb dozis ga<strong>da</strong>Warbebisas.<br />

y u r i s w v e T e b i<br />

rekomendebulia, rom yvela bavSvSi mwvave otitiT un<strong>da</strong> moxdes<br />

tkivilis Sefaseba <strong>da</strong> tkivilis arsebobis SemTxvevaSi un<strong>da</strong> <strong>da</strong>iniSnos<br />

analgetikebi. un<strong>da</strong> gaviTvaliswinoT, tkivili mwvave otitis dros, rogorc<br />

wesi, TavisiT gaivlis. amitom, aucileblobis SemTxvevaSi efeqturi <strong>da</strong><br />

usafrTxo analgetikebis xelmisawvdomoba ufro mniSvnelovania, vidre is,<br />

Tu romeli medikamenti gamoviyenoT. es preparatebia oraluri wveTebi<br />

(paracetamoli an ibuprofeni) an yuris topikuri wveTebi (rekomen<strong>da</strong>cia A).<br />

pacientebSi, romlebTanac saeWvoa <strong>da</strong>fis apkis perforacia <strong>da</strong>/an<br />

gamonadeni yuri<strong>da</strong>n, Tavi un<strong>da</strong> avaridoT garegani saSualebebis moxmarebas,<br />

radgan maT gamoyenebas SesaZloa Tan mohyves Zlieri Tavbrusxveva <strong>da</strong><br />

Rebineba.<br />

a n t i b i o t i k e b i .<br />

otitis dros antibiotikebs eqimebi sxva<strong>da</strong>sxva sixSiriT iyeneben (32%<br />

holandiaSi <strong>da</strong> 98%-iT avstraliasa <strong>da</strong> aSS-Si).<br />

kvlevebis meta-analizi gviCvenebs, rom antibiotikebi ar amcireben<br />

tkivils mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n 24 saaTis ganmavlobaSi. Tumca<br />

antibiotikebis adreuli gamoyeneba amcirebs tkivilis ganviTarebis risks<br />

40%-iT. amave dros, antibiotikebis gamoyeneba ar amcirebs otitis momdevno<br />

epizodebis sixSires an siyruis ganviTarebis risks. gar<strong>da</strong> amisa,<br />

antibiotikebis gamoyenebisas TiTqmis ormagdeba Rebinebis, diareis <strong>da</strong><br />

gamonayaris riski. antibiotikebis ar gamoyeneba ar ganapirobebs <strong>da</strong>avadebis<br />

mZime mimdinareobas (sarwmunoebis done I).<br />

27

gar<strong>da</strong> amisa, naCvenebia, rom im bavSvebSi, romlebSic antibiotikebi ar<br />

iyo <strong>da</strong>sawyisi<strong>da</strong>nve gamoyenebuli, Zalian iSviaTia mastoiditis an sxva<br />

garTulebebis ganviTarebis riski.<br />

antibiotikebi gamoyenebuli un<strong>da</strong> iqnes rutinulad 2 wlamde asakis<br />

bavSvebSi an orxrivi otitis dros.<br />

mwvave otitis dros antibiotiki ar un<strong>da</strong> iyos <strong>da</strong>avadebis<br />

<strong>da</strong>sawyisSive rutinulad gamoyenebuli.<br />

antibiotikebi gamoyenebuli un<strong>da</strong> iqnes 2 wlamde asakis bavSvebSi an<br />

orxrivi otitis dros.<br />

a n t i b i o t i k e b i s m o g v i a n e b i T i g a m o y e n e b a .<br />

antibiotikebis mogvianebiT <strong>da</strong>niSvnasTan <strong>da</strong>kavSirebul kvlevaSi<br />

gamoyenebuli iyo ori strategia: <strong>da</strong>uyovneblivi antibiotikoTerapia <strong>da</strong><br />

mogvianebiTi antibiotikoTerapia (mdgomareobis ucvlelobis gamo<br />

antibiotiki <strong>da</strong>niSnuli iqna 72 saaTis Semdeg). <strong>da</strong>dgin<strong>da</strong>, rom: (a)<br />

<strong>da</strong>uyovneblivi antibiotikoTerapia simptomur efeqturobas iZleva pirveli<br />

24 saaTis Semdeg, maSin, rodesac simptomebi ukve Semcirebulia. (b)<br />

<strong>da</strong>uyovneblivi antibiotikoTerapia 10%-iT zrdis diareis sixSires; (g)<br />

mogvianebiTi antibiotikoTerapiis jgufSi antibiotikebi gamoyenebul iqna<br />

mxolod 24%-Si; (d) mogvianebiTi antibiotikoTerapia amcirebs<br />

antibiotikebis gamoyenebis sixSires 76%-iT (sarwmunoebis done I).<br />

adeqvaturi analgezia <strong>da</strong> “<strong>da</strong>velodoT <strong>da</strong> <strong>da</strong>vakvirdeT’ midgoma ufro<br />

gonivrulia, <strong>da</strong>uyovnebliv antibiotikoTerapiasTan Se<strong>da</strong>rebiT.<br />

mwvave otitis dros mogvianebiTi antibiotikoTerapia<br />

(mdgomareobis ucvlelobis gamo antibiotikis <strong>da</strong>niSvna 72 saaTis<br />

Semdeg) SeiZleba gamoyenebuli iqnes <strong>pirveladi</strong> <strong>jan<strong>da</strong>cvis</strong><br />

praqtikaSi.<br />

a n t i b i o t i k e b i s a r C e v a n i d a x a n g r Z l i v o b a .<br />

mravali kvleviT <strong>da</strong>dgenilia mwvave otitis gamomwvevi ori uxSiresi<br />

baqteriuli gamomwvevi: Streptococcus pneumoniae <strong>da</strong> Haemophi;us influanzae.<br />

Se<strong>da</strong>rebiT iSviaTia Moraxela catarrhalis. aqe<strong>da</strong>n gamondinare, arCevis preparats<br />

warmoadgens amoqsicilini (60-90 mg/kg/dReSi or miRebaze). bavSvebSi<br />

SeiZleba doza SerCeuli iqnes asakis <strong>da</strong> riskis gaTvaliswinebiT. Tu<br />

bavSvis asaki 2 welze metia, is ar izrdeba organizebul koleqtivebSi <strong>da</strong><br />

bolo 3 Tvis ganmavlobaSi antibiotiki gamoyenebuli ar yofila,<br />

rekomendebuli dozaa 40 mg/kg/dReSi. sxva SemTxvevebSi amoqsicilinis<br />

rekomendebuli dozaa 80 mg/kg/dReSi (rekomen<strong>da</strong>cia A).<br />

Tu 72 saaTis Semdeg mkurnaloba uefeqtoa, an Tu pirveli rigis<br />

preparatze aRiniSna alergiuli reaqcia, rekomendebulia<br />

28

amoqsicilini/klavulinis mJavis an peroraluri cefalosporinebis<br />

gamoyeneba (rekomen<strong>da</strong>cia C).<br />

Tu simptomebi grZeldeba amoqsicilini/klavulinatis miRebis<br />

Semdegac, an Tu medikamentis peroraluri miReba SeuZlebelia,<br />

mizanSewonilia ceftriaqsonis intramuskularuli ineqciebi 1-3 dRis<br />

ganmavlobaSi (rekomen<strong>da</strong>cia C).<br />

amoqsiciliniT Terapiis uefeqtobis SemTxvevaSi ar aris<br />

rekomendebuli makrolidebis gamoyeneba (rekomen<strong>da</strong>cia A).<br />

mkurnalobis optimaluri xangrZlivoba gansxvavebulia sxva<strong>da</strong>sxva<br />

qveyanaSi, ase magaliTad, did britaneTSi upiratesobas aniWeben 5 dRian<br />

kurss, holandiaSi 7 dRians, xolo CrdiloeT amerikaSi 10 dRian kurss.<br />

Cochrane-is mimoxilvis mixedviT gaurTulebeli mwvave otitis dros<br />

mkurnalobis 5 dRiani kursi efeqturia.<br />

Cvili asakis bavSvebSi mkurnalobis optimaluri xangrZlivoba<br />

<strong>da</strong>dgenili ar aris (sarwmunoebis done I).<br />

garTulebuli mwvave otitis dros <strong>da</strong> riskis jgufis bavSvebSi<br />

mizanSewonilia 10 dRiani antibiotikoTerapia (rekomen<strong>da</strong>cia A).<br />

gaurTulebeli mwvave otitis dros rekomendebulia 5 dRiani<br />

antibiotikoTerapia.<br />

<br />

garTulebeli mwvave otitis dros <strong>da</strong> riskis jgufis bavSvebSi<br />

rekomendebulia 10 dRiani antibiotikoTerapia.<br />

d e k o n g e s t a n t e b i , a n t i h i s t a m i n u r i p r e p a r a t e b i d a<br />

m u k o l i t i k e b i .<br />

Cochrane-is mimoxilva dekongestantebTan <strong>da</strong> antihistaminebTan<br />

<strong>da</strong>kavSirebiT 13 kvlevis analizis safuZvelze askvnis, rom maT gamoyenebas<br />

ar moaqvs <strong>da</strong>matebiTi sargebloba mkurnalobis xangrZlivobis, simptomebis<br />

Semcirebis, qirurgiuli Carevis an sxva garTulebebis Tavi<strong>da</strong>n acilebis<br />

TvalsazrisiT. mxolod maTi kombinirebuli gamoyenebis SemTxvevaSi nanaxi<br />

iqna persistirebuli otitis sixSiris Semcireba. amave dros, <strong>da</strong>fiqsir<strong>da</strong><br />

maTi gverdiTi movlenebis gamovlenis riskis mateba. amitom uefeqtobis <strong>da</strong><br />

gverdiTi movlenebis arsebobis gamo antihistaminuri preparatebis,<br />

dekongestantebis an maTi kombinirebuli gamoyenebis, aseve mukolitikebis<br />

gamoyeneba mwvave otitebis dros rekomendebuli ar aris.<br />

mwvave otitis dros antihistaminuri preparatebis <strong>da</strong><br />

dekongestantebis gamoyeneba rekomendebuli ar aris.<br />

morecidive mwvave otiti.<br />

mwvave otitis mkurnalobis taqtikis gansazRvisas gaTvaliswinebuli<br />

un<strong>da</strong> iqnes morecidive mwvave otitis diagnozis SesaZlebloba. aseT<br />

29

SemTxvevaSi antibiotikoTerapia ufro agresiuli <strong>da</strong> adreuli un<strong>da</strong> iyos.<br />

morecidive mwvave otitis diagnozi ismeba maSin, Tu 6-Tviani periodis an<br />

Semodgoma-zamTris <strong>respiraciuli</strong> infeqciebis matebis periodis<br />

ganmavlobaSi aRiniSna mwvave otitis 3 epizodi an wlis ganmavlobaSi<br />

mwvave otitis 4 an meti epizodia.<br />

morecidive mwvave otitis ganviTarebis risks warmoadgenen bavSvebi<br />

<strong>da</strong>unis sindromiT, mwvave otitis adreuli pirveli epizodiT (6 Tvemde<br />

asakSi, morecidive mwvave otitis ojaxuri anamneziT, bavSvebi organizebul<br />

koleqtivebSi, xelovnuri kvebis bavSvebi (rekomen<strong>da</strong>cia B).<br />

Semdgomi <strong>da</strong>kvirveba<br />

Tu mdgomareoba ar umjobesdeba, aucilebelia bavSvis ganmeorebiTi<br />

gamokvleva 48-72 saaTis Semdeg.<br />

umravles SemTxvevaSi mwvave otiti gamojanmrTelebiT mTavrdeba.<br />

SesaZlebelia arasruli gankurneba an gamonadenis gaxangrZliveba. am dros<br />

aucilebelia ganmeorebiTi gamokvleva 2 kviris Semdeg. Tu problema<br />

grZeldeba, aucilebelia otolaringologTan referali.<br />

perforaciis SemTxvevaSi aucilebelia mSoblebis informireba, rom es<br />

ar aris seriozuli garTuleba. aseT SemTxvevebSi aucilebelia Tavi<strong>da</strong>n<br />

aviciloT yurSi wylis moxvedra an bambis tamponis gamoyeneba.<br />

ganmeorebiTi gamokvleva saWiroa 6 kviris Semdeg.<br />

referali<br />

saswrafod ga<strong>da</strong>agzavneT otolaringologTan pacienti, Tu <strong>da</strong>ewyo<br />

gareTa sasmen milSi Cirqovani gamonadeni, gansakuTrebiT Tu igi<br />

pulsirebad xasiaTs atarebs.<br />

saswrafod ga<strong>da</strong>agzavneT otolaringologTan pacienti, Tu<br />

gamoCn<strong>da</strong> iseTi garTulebebi, rogoricaa saxis nervis paralizi an<br />

mastoiditi.<br />

ga<strong>da</strong>agzavneT otolaringologTan SerCeviTad, Tu eqvsi Tvis<br />

ganmavlobaSi aRiniSna mwvave otitis sami an meti epizodi, an<br />

oTxi epizodi aRiniSna 12 Tvis ganmavlobaSi.<br />

ga<strong>da</strong>agzavneT otolaringologTan, Tu mkurnalobis <strong>da</strong>mTavrebis<br />

Semdeg eWvi gaqvT smenis deficitze (gamoikvlieT yvela avadmyofi.<br />

CurCuli un<strong>da</strong> ismodes <strong>da</strong>axloebiT 6 metrze).<br />

gaidlainis miRebis wyaro. winamdebare gaidlaini warmoadgenis<br />

sxva<strong>da</strong>sxva gaidlainebis (ix. literatura) Sejerebis <strong>da</strong> a<strong>da</strong>ptaciis Sedegs.<br />

30

literatura<br />

1. Diagnosis and management of childhood otitis media in primary care. Scottish<br />

Intercollegiate Guidelines Network. 2003<br />

2. Management of sore throat and indications for tonsilectomy. Scottish Intercollegiate<br />

Guidelines Network. 1999<br />

3. S.Singh, J.Dolan, R. Centor. Optimal management of adults with pharyngitis – a multicriteria<br />

decision analysis. BMC Medicl informatics and Decision Making, 2006, 6:14.<br />

4. Tonsillitis and pharingitis in children. National Guideline Clearinghouse, 2005.<br />

5. Viral URI in adults and children. National Guideline Clearinghouse, 2005.<br />

6. Evi<strong>da</strong>nce based clinical practice guideline for children with acute bacterial sinusitis in<br />

children 1 to 18 years of age. National Guideline Clearinghouse, 2005.<br />

7. Principles of appropriate antibioic use for acute pharyngitis in adults. Ann Intern Med<br />

2001; 134, 509-517.<br />

8. Diagnosis and management of Group A streptococal pharyngitis: a practice guideline.<br />

Clin Infect Dis, 1997;25:574-83<br />

9. Guideline for the diagnosis and treatment of acute pharingitis. Alberta medical<br />

association, 2001<br />

10. Management of acute URTI. A clinical Guideline from Colorado Clinical Guideline<br />

Collaborative, 2002<br />

11. Clinical practice guideline: management of sinusitis. Pediatrics, 2001, vol.108, n 3,p.<br />

798-808<br />

31

12. Principles of appropriate antibioic use for treatment of ARTI in adults. Ann Intern Med<br />

2001; 134, 479-486.<br />

13. Adderson EE: Preventing otitis media: medical approaches. Pediatr Ann 1998 Feb; 27(2):<br />

101-7<br />

14. Aronovitz GH: Antimicrobial therapy of acute otitis media: review of treatment<br />

recommen<strong>da</strong>tions. Clin Ther 2000 Jan; 22(1): 29-39.<br />

15. Bitnun A, Allen UD: Medical therapy of otitis media: use, abuse, efficacy, and morbidity.<br />

J Otolaryngol 1998; 27 Suppl 2: 26-36.<br />

16. Bluestone CD: Clinical course, complications and sequelae of acute otitis media. Pediatr<br />

Infect Dis J 2000 May; 19(5 Suppl): S37-46.<br />

17. Bluestone CD: Role of surgery for otitis media in the era of resistant bacteria. Pediatr<br />

Infect Dis J 1998 Nov; 17(11): 1090-8; discussion 1099-100.<br />

18. Blumer JL: Fun<strong>da</strong>mental basis for rational therapeutics in acute otitis media. Pediatr<br />

Infect Dis J 1999 Dec; 18(12): 1130-40.<br />

19. Bradley JS: Oral vs. intramuscular antibiotic therapy for acute otitis media: which is best<br />

Pediatr Infect Dis J 1999 Dec; 18(12): 1147-51.<br />

20. Byington CL: The diagnosis and management of otitis media with effusion. Pediatr Ann<br />

1998 Feb; 27(2): 96-100.<br />

21. Carlson L, Scudder L: Controversies in the management of pediatric otitis media. Are<br />

more definitive answers on the horizon. Adv Nurse Pract 2004 Feb; 12(2): 73-7<br />

22. Chartrand SA, Pong A: Acute otitis media in the 1990s: the impact of antibiotic<br />

resistance. Pediatr Ann 1998 Feb; 27(2): 86-95.<br />

23. Chonmaitree T, Heikkinen T: Role of viruses in middle-ear disease. Ann N Y Acad Sci<br />

1997 Dec 29; 830: 143-57.<br />

24. Chonmaitree T: Viral and bacterial interaction in acute otitis media. Pediatr Infect Dis J<br />

2000 May; 19(5 Suppl): S24-30.<br />

25. Conrad DA: Should acute otitis media ever be treated with antibiotics Pediatr Ann 1998<br />

Feb; 27(2): 66-7, 70-4.<br />

26. Daly KA, Giebink GS: Clinical epidemiology of otitis media. Pediatr Infect Dis J 2000<br />

May; 19(5 Suppl): S31-6.<br />

27. Foshee WS, Steele RW: Should prophylactic antibiotics be used for the otitis-media–<br />

prone child Pediatr Infect Forum 2000; 2: 2-7.<br />

28. Glasziou PP, Hayem M, Del Mar CB: Antibiotics for acute otitis media in children.<br />

Cochrane Database Syst Rev 2000; (2): CD000219.<br />

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29. Heikkinen T, Chonmaitree T: Increasing importance of viruses in acute otitis media. Ann<br />

Med 2000 Apr; 32(3): 157-63.<br />

30. Hoberman A, Paradise JL, Cohen R: Duration of therapy for acute otitis media. Pediatr<br />

Infect Dis J 2000 May; 19(5): 471-3 [Medline] .<br />

31. Urs B. Schaad, MD; Ralph Mütterlein, MD and Heidi Goffin, MD. Immunostimulation<br />

With OM-85 in Children With Recurrent Infections of the Upper Respiratory Tract A<br />

Double-Blind, Placebo-Controlled Multicenter Study. Chest. 2002;122:2042-2049.<br />

32. Jung TT, Hanson JB: Classification of otitis media and surgical principles. Otolaryngol<br />

Clin North Am 1999 Jun; 32(3): 369-83.<br />

33. Kalei<strong>da</strong> PH, Fireman P: Diagnostic assessment of otitis media. Clin Allergy Immunol<br />

2000; 15: 247-62.<br />

34. Klein JO: Review of consensus reports on management of acute otitis media. Pediatr<br />

Infect Dis J 1999 Dec; 18(12): 1152-5.<br />

35. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al: Short course antibiotics for<br />

acute otitis media. Cochrane Database Syst Rev 2000; (2): CD001095.<br />

36. Ah-See, K. (2005) Sinusitis (acute). Clinical Evidence. Volume<br />

13http://www.clinicalevidence.com/<br />

37. Alberta Medical Association (2000) Diagnosis and management of acute bacterial<br />

sinusitis: children. Summary of the Alberta clinical practice guideline, December 2000.<br />

Alberta Medical Association. http://www.albertadoctors.org/<br />

38. Alberta Medical Association (2005) Diagnosis and management of acute bacterial<br />

sinusitis: adults. Summary of the Alberta clinical practice guideline, December 2000.<br />

Alberta Medical Association. http://www.albertadoctors.org/<br />

39. Anon, J.B., Jacobs, M.R., Poole, M.D. et al (2004) Antimicrobial treatment guidelines for<br />

acute bacterial rhinosinusitis. Otolaryngology - Head & Neck Surgery 130(Suppl 1), 1-<br />

45. [erratum appears in Otolaryngol Head Neck Surg. 2004 Jun;130(6):794-6].<br />

40. Benninger, M.S., Sedory Holzer, S.E. and Lau, J. (2000) Diagnosis and treatment of<br />

uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care<br />

Policy and Research evidence-based report. Otolaryngology - Head & Neck Surgery<br />

122(1), 1-7.<br />

41. Blomgren, K., Alho, O.P., Ertama, L. et al (2005) Acute sinusitis: Finnish clinical<br />

practice guidelines. Scandinavian Journal of Infectious Diseases 37(4), 245-250.<br />

42. Brook, I., Gooch, W.M., III, Jenkins, S.G. et al (2000) Medical management of acute<br />

bacterial sinusitis. Recommen<strong>da</strong>tions of a clinical advisory committee on pediatric and<br />

adult sinusitis. Annals of Otology, Rhinology, & Laryngology - Supplement 182, 2-20.<br />

33

43. Elective Services, New Zealand Ministry of Health (2003) Primary care management<br />

guidelines: rhinosinusitis. New Zealand Ministry of Health.<br />

http://www.electiveservices.govt.nz.<br />

44. Elies, W. and Huber, K. (2004) Short-course therapy for acute sinusitis: how long is<br />

enough Treatments in Respiratory Medicine 3(5), 269-277.<br />

stacionarSi<br />

mwvave sinusitis marTvis<br />

protokoli<br />

definicia<br />

mwvave sinusiti paranazaluri sinusebis lorwovani garsis anTebiTi<br />

<strong>da</strong>zianebaa, romelic gamowveulia <strong>da</strong>xSul RruSi baqteriebis zrdiT <strong>da</strong><br />

romlis xangrZliobac 4 kviraze naklebia. sinusitis ganviTareba<br />

uxSiresad iwyeba rinitis fonze, ris gamoc mas xSir SemTxvevaSi uwodeben<br />

rinosinusits.<br />

<strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebi<br />

<strong>da</strong>avadebis diagnostika efuZneba <strong>da</strong>avadebis anamnezs, klinikur<br />

suraTs, simptomebis xangrZlivobas, obieqtur gasinjvas <strong>da</strong>, saWiroebisas,<br />

rentgenologiuri gamokvlevis Sedegebs.<br />

sinusitis arc erTi klinikuri niSani <strong>da</strong>moukideblad ar aris<br />

mgrZnobiare <strong>da</strong> specifiuri diagnozis <strong>da</strong>sasmelad.<br />

baqteriuli sinusitis klinikuri ni Snebia:<br />

• zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14<br />

dRis ganmavlobaSi <strong>da</strong> romelsac Tan axlavs 2 niSani:<br />

• cxviri<strong>da</strong>n lorwovan - Cirqovani gamonadeni<br />

<strong>da</strong><br />

• gaxangrZlivebuli ara<strong>da</strong>makmayofilebeli mdgomareoba.<br />

34

aseve SesaZlebelia:<br />

• cxeleba;<br />

• xvela;<br />

• agzneba;<br />

• saxis tkivili.<br />

obieqturad SeiZleba gamovlindes:<br />

• saxis Sesieba an eriTema <strong>da</strong>zianebis areSi;<br />

• mgrZnobeloba sinusis palpaciis an perkusiis dros (palpaciisas<br />

mcire asakis bavSvebSi saxis tkivili <strong>da</strong> sinusis mgrZnobeloba ar<br />

vlindeba, Tumca es simptomebi kargi indikatoria saskolo asakis<br />

bavSvebsa <strong>da</strong> mozardebSi);<br />

• periorbitaluri Sesiveba;<br />

• cxviris lorwovani garsis eriTema an SeSupeba;<br />

• ZiriTadi kbilebis mgrZnobeloba;<br />

• Tanmxlebi Sua yuris anTeba bavSvebSi.<br />

ZiriTadi simptomebi, romelsac efuZneba diagnozi:<br />

zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14<br />

dRis ganmavlobaSi;<br />

cxviriT sunTqvis blokireba/cxviri<strong>da</strong>n gamonadeni (SeiZleba mxolod<br />

lorwovani, Sesqelebuli, lorwovan-Cirqovani);<br />

persistuli xvela, romelic Zlierdeba RamiT.<br />

Se<strong>da</strong>rebiT iSviaTad vlindeba gulisreva, yuris <strong>da</strong> yelis tkivili,<br />

saxis tkivili, SeSupeba.<br />

diagnostikur-laboratoriuli testebi<br />

sawyis etapze sinusitze saeWvo SemTxvevebSi rutinuli<br />

rentgenologiuri kvleva ar aris saWiro. ar aris rekomendebuli<br />

sinusebis rentgenografiis Catareba 6 wlamde asakSic. sinusitis<br />

mkurnaloba SesaZlebelia <strong>da</strong>iwyos mxolod klinikur suraTze<br />

<strong>da</strong>yrdnobiT.<br />

rentgenologiuri kvlevis Catareba saWiroa Semdeg SemTxvevebSi:<br />

mwvave sinusitis diagnozisas, Tu saeWvoa subperiostuli an<br />

orbitaluri abscesi;<br />

mwvave sinusitis diagnozisas, Tu saeWvoa intrakraniuli garTulebebi;<br />

Tu mkurnalobis miuxe<strong>da</strong>vad ar aris gaumjobeseba <strong>da</strong> saWiroa<br />

diagnozis <strong>da</strong><strong>da</strong>stureba.<br />

35

yvela SemTxvevaSi rentgenografia un<strong>da</strong> Catardes pacientis<br />

vertikalur poziciaSi, raTa rentgenogramaze Sefasdes sinusSi haerisiTxis<br />

done.<br />

gaurTulebeli mwvave sinusitis dros sisxlis saerTo analizis an<br />

nazofaringiuli kulturis rutinulad Catareba ar aris rekomendebuli.<br />

garTulebuli sinusitebis SemTxvevaSi diagnostikis “oqros<br />

stan<strong>da</strong>rtad” iTvleba sinusis aspiracia <strong>da</strong> baqteriuli kulturis<br />

Seswavla.<br />

mwvave sinusitis arsebobas gamoricxavs simptomebis persistireba 4<br />

kviraze metad.<br />

mkurnaloba<br />

antibiotikoTerapia<br />

baqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis<br />

drenireba <strong>da</strong> paTologiuri baqteriebis zrdis Seferxeba. antibiotiko-<br />

Terapiis Cvenebaa:<br />

• simptomebis persistireba (magaliTad, Tu klinikuri niSnebi<br />

grZeldeba 7 - 10 dReze meti);<br />

• mZime simptomatika (mag: profuzuli Cirqovani gamonadeni cxviri<strong>da</strong>n,<br />

saxis tkivili <strong>da</strong> sistemuri <strong>da</strong>zianebis niSnebi);<br />

• pacientis mdgomareobis <strong>da</strong> simptomebis gauareseba.<br />

pirveli rigis preparats miekuTvneba amoqsicilini. Tu arsebobs<br />

alergiuli anamnezi penicilinebis jgufis antibiotikebis mimarT SeiZleba<br />

<strong>da</strong>iniSnos azitromicini <strong>da</strong> klaritromicini, <strong>da</strong>dgenilia maTi maRali<br />

efeqturoba sinusitis gamomwvevebis mimarT.<br />

meore rigis preparatebs miekuTvneba: ko-amoqsiklavi, cefuroqsimi,<br />

levofloqsacini (12 wlis zemo asakSi).<br />

ana lgetiuri <strong>da</strong> an tipiretuli saSualebebi<br />

tkivilisa <strong>da</strong> temperaturuli reaqciis kupirebis mizniT bavSvebSi<br />

naCvenebia paracetamolis an iboprufenis gamoyeneba.<br />

dekongestantebi<br />

intranazaluri dekongestantebis gamoyeneba moklevadiani kursiT<br />

SesaZlebelia sinusitis samkurnalod, intranazaluri dekongestantebis<br />

xangrZlivi droiT (7 dRe <strong>da</strong> meti) gamoyeneba ar aris rekomendebuli.<br />

sxva saSualebebi<br />

ar arsebobs klinikuri mtkicebulebebi nazalurad fiziologiuri<br />

xsnaris gamoyenebis Sesaxeb. Tumca SesaZlebelia fiziologiuri xsnaris<br />

gamoyenebam xeli SeuSalos fufxebis warmoqmas <strong>da</strong> gaaTxelos sekreti,<br />

rac gaaioloebs mis drenaJs.<br />

<strong>da</strong>kvirveba<br />

36

Tu pacients mkurnaloben antibiotikebiT <strong>da</strong> misi mdgomareoba ar<br />

umjobesdeba, an Tu ver xerxdeba antibiotikis miReba, magaliTad Rebinebis<br />

SemTxvevaSi, ganmeorebiTi viziti saWiroa Catardes 72 saaTSi.<br />

Tu pacientis mdgomareoba antibiotikoTerapiis fonze ar umjobesdeba,<br />

saWiroa:^<br />

• ga<strong>da</strong>isinjos diagnozis adekvaturoba;<br />

• Sefasdes garTulebebis arseboba;<br />

• Sefasdes, Tu ramdenad asrulebs pacienti eqimis <strong>da</strong>niSnulebas.<br />

Tu pacienti ar asrulebs sworad eqimis <strong>da</strong>niSnulebas:<br />

• SeiZleba gagrZeldes mocemuli antibiotiki;<br />

• Tu antibiotikze aRiniSneba Rebineba, igi un<strong>da</strong> Seicvalos sxva<br />

pirveli rigis preparatiT an <strong>da</strong>iniSnos saineqcio antibiotiki,<br />

sanam ar moxdeba Rebinebis kupireba, ris Semdegac kvlav xdeba<br />

ga<strong>da</strong>svla oralur antibiotikze.<br />

Tu pacienti sworad asrulebs eqimis <strong>da</strong>niSnulebas:<br />

• saWiroa meore rigis antibiotikebis gamoyeneba<br />

Tu saeWvoa baqteriuli sinusitis garTuleba, aucilebelia<br />

pacientis referali <strong>da</strong> otorinlarigologis, ofTalmologis,<br />

neiroqirurgis konsultacia.<br />

protokolis wyaro. winamdebare protokoli efuZneba saqarTvelos<br />

<strong>respiraciuli</strong> asociaciis “mwvave sinusitis marTvis gaidlains”.<br />

stacionarSi<br />

37

definicia<br />

mwvave otitis marTvis<br />

protokoli<br />

ar arsebobs otitis SeTanxmebuli definicia. samuSao definiciad<br />

mowodebulia Sua yuris anTeba swrafi ganviTarebiT adgilobrivi (yuris<br />

tkivili) <strong>da</strong> zogadi simptomatikiT (cxeleba, gaRizianeba, cudi Zili).<br />

SesaZlebelia adgili hqondes ze<strong>da</strong> sasunTqi gzebis <strong>da</strong>avadebisTvis<br />

<strong>da</strong>maxasiaTebel simptomebs: xvelas <strong>da</strong> rinoreas.<br />

<strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebi<br />

mwvave otitis diagnozi moiTxovs: <strong>da</strong>avadebis simptomebis ganviTarebis<br />

mwvave <strong>da</strong>sawyiss; gamonadenis arsebobas Sua yurSi (timpanuri membranis<br />

SeSupeba, timpanuri membranis mobilurobis SezRudva an ararseboba,<br />

otorea); Sua yuris anTebis niSnebis <strong>da</strong> simptomebis arsebobas (timpanuri<br />

membranis hiperemia, otalgia).<br />

klinikuri ni Snebi<br />

Sua yuris anTebis uxSiresi simptomebia: tkivili, cxeleba,<br />

gaRizianebadoba, otorea (gamonadeni yuri<strong>da</strong>n), leTargia, anoreqsia <strong>da</strong><br />

Rebineba. specifiuri niSnebis nakleboba, gansakuTrebiT or wlamde asakSi,<br />

arTulebs Sua yuris mwvave anTebis dignozis <strong>da</strong>dgenas.<br />

Sua yuris anTeba gamonadeniT SesaZloa saerTod simptomebis gareSe<br />

mimdinareobdes <strong>da</strong> gamovlenil iyos mxolod urTierTobis, qcevis,<br />

swavlis <strong>da</strong> metyvelebis problemebiT.<br />

mwvave otitis diagnostika<br />

klinikuri niSnebi <strong>da</strong> otoskopiuri kvleva.<br />

rekomendebulia pacientebSi morecidive mwvave otitiT<br />

gansakuTrebuli yuradReba <strong>da</strong>eTmos Civils smenis <strong>da</strong>qveiTebis, metyvelebis<br />

Seferxebis Sesaxeb.<br />

aucileblad un<strong>da</strong> iqnes gaTvaliswinebuli, rom otitisaTvis<br />

<strong>da</strong>maxasiaTebeli simptomebi <strong>da</strong> niSnebi SeiZleba gaqres membranis<br />

perforaciis Semdeg. gar<strong>da</strong> amisa, <strong>da</strong>avadebis ga<strong>da</strong>tanis Semdeg Sua<br />

yurSi gamonadeni SeiZleba <strong>da</strong>rCes mwvave otitis simptomebis<br />

gaqrobis Semdeg<br />

MmarTva<br />

a n a l g e t i k e b i . tkivilis SemTxvevaSi aucilebelia analgetikebis<br />

(acetaminofeni, ibuprofeni) amoyeneba. tkivilis marTva, gansakuTrebiT<br />

<strong>da</strong>avadebis pirvel 24 saaTSi, aucilebelia antibiotikoTerapiis<br />

miuxe<strong>da</strong>vad. tkivilis marTvaSi paracetamols upiratesoba un<strong>da</strong> mieniWos<br />

arasteroiduli anTebis sawinaaRmdego saSualebebTan Se<strong>da</strong>rebiT am<br />

ukanasknelis gverdiTi movlenebis gamo (sarwmunoebis done I). mSoblebs<br />

38

un<strong>da</strong> miewodoT informacia mosalodneli safrTxis Sesaxeb dozis<br />

ga<strong>da</strong>Warbebisas.<br />

y u r i s w v e T e b i<br />

rekomendebulia, rom yvela bavSvSi mwvave otitiT un<strong>da</strong> moxdes<br />

tkivilis Sefaseba <strong>da</strong> tkivilis arsebobis SemTxvevaSi un<strong>da</strong> <strong>da</strong>iniSnos<br />

analgetikebi. un<strong>da</strong> gaviTvaliswinoT, tkivili mwvave otitis dros, rogorc<br />

wesi, TavisiT gaivlis. amitom, aucileblobis SemTxvevaSi efeqturi <strong>da</strong><br />

usafrTxo analgetikebis xelmisawvdomoba ufro mniSvnelovania, vidre is,<br />

Tu romeli medikamenti gamoviyenoT. es preparatebia oraluri wveTebi<br />

(paracetamoli an ibuprofeni) an yuris topikuri wveTebi. pacientebSi,<br />

romlebTanac saeWvoa <strong>da</strong>fis apkis perforacia <strong>da</strong>/an gamonadeni yuri<strong>da</strong>n,<br />

Tavi un<strong>da</strong> avaridoT garegani saSualebebis moxmarebas, radgan maT<br />

gamoyenebas SesaZloa Tan mohyves Zlieri Tavbrusxveva <strong>da</strong> Rebineba.<br />

a n t i b i o t i k e b i .<br />

antibiotikebi gamoyenebuli un<strong>da</strong> iqnes rutinulad 2 wlamde asakis<br />

bavSvebSi an orxrivi otitis dros.<br />

arCevanis preparats warmoadgens amoqsicilini.<br />

Tu amoqsiciliniT 72 saaTiani Terapia uefeqtoa, an Tu pirveli rigis<br />

preparatze aRiniSna alergiuli reaqcia, rekomendebulia<br />

amoqsicilini/klavulinis mJavis an peroraluri cefalosporinebis<br />

gamoyeneba.<br />

Tu simptomebi grZeldeba amoqsicilini/klavulinatis miRebis<br />

Semdegac, an Tu medikamentis peroraluri miReba SeuZlebelia,<br />

mizanSewonilia ceftriaqsonis intramuskularuli ineqciebi 1-3 dRis<br />

ganmavlobaSi.<br />

amoqsiciliniT Terapiis uefeqtobis SemTxvevaSi ar aris<br />

rekomendebuli makrolidebis gamoyeneba.<br />

gaurTulebeli mwvave otitis dros mkurnalobis 5 dRiani kursi<br />

efeqturia. garTulebuli mwvave otitis dros <strong>da</strong> riskis jgufis bavSvebSi<br />

mizanSewonilia 10 dRiani antibiotikoTerapia (rekomen<strong>da</strong>cia A).<br />

mwvave otitis dros antihistaminuri preparatebis <strong>da</strong> dekongestantebis<br />

rutinuli gamoyeneba rekomendebuli ar aris.<br />

Semdgomi <strong>da</strong>kvirveba <strong>da</strong> referali<br />

Tu mdgomareoba ar umjobesdeba, aucilebelia bavSvis ganmeorebiTi<br />

gamokvleva 48-72 saaTis Semdeg.<br />

otolaringologTan referali aucilebelia: Tu <strong>da</strong>ewyo gareTa sasmen<br />

milSi Cirqovani gamonadeni, gansakuTrebiT Tu igi pulsirebad xasiaTs<br />

atarebs; gamoCn<strong>da</strong> iseTi garTulebebi, rogoricaa saxis nervis paralizi an<br />

39

mastoiditi; Tu eqvsi Tvis ganmavlobaSi aRiniSna mwvave otitis sami an<br />

meti epizodi, an oTxi epizodi aRiniSna 12 Tvis ganmavlobaSi; Tu<br />

mkurnalobis <strong>da</strong>mTavrebis Semdeg eWvi gaqvT smenis deficitze (gamoikvlieT<br />

yvela avadmyofi. CurCuli un<strong>da</strong> ismodes <strong>da</strong>axloebiT 6 metrze).<br />

protokolis wyaro. winamdebare protokoli efuZneba saqarTvelos<br />

<strong>respiraciuli</strong> asociaciis “mwvave otitis marTvis gaidlains”.<br />

mwv ave si nusitis mar Tvis al goritmi<br />

mw vave si nusitis diagnostika<br />

pa cienti mw vave mZ ime<br />

im onokompetentur pa cientSi<br />

si nusitiT<br />

bavSvi:<br />

bavSvi <strong>da</strong> mozrdili:<br />

• cxviri<strong>da</strong>n gamonadenis gaxangrZliveba;<br />

• maRali (>39 0 C) an mudmivi<br />

• xveleba dRis saaTebSi;<br />

cxeleba (>3-4 dReze)<br />

• 10-14 dReSi ar aris gaumjobeseba.<br />

• periorbituli SeSupeba<br />

mozrdili:<br />

• 10-14 dReSi ar aris<br />

• Cirqovani gamonadeni cxviri<strong>da</strong>n;<br />

gaumjobeseba<br />

• tkivili ze<strong>da</strong> ybis areSi (gans. calmxrivi);<br />

• saxis/kbilis Zlieri<br />

• cal mxares sinusis mgrZnobeloba;<br />

tkivili<br />

• sawyisi gaumjobesebis Semdeg mdgomareobis<br />

• am simptomebis arsebobisas,<br />

gauareseba;<br />

miuxe<strong>da</strong>vad maTi<br />

• gaumjobesebis ararseboba7-10 dRis Semdeg; ai rCieT erTi<br />

xangrZlivobisa,<br />

ai rCieT<br />

saWiroa<br />

erTi<br />

• sinusis rentgenografia morecidive an qr.<br />

<strong>da</strong>uyovneblivi <strong>da</strong>xmareba<br />

• amoqsicilini:<br />

• amoqsicilini:<br />

sinusitis dros.<br />

sim ptomuri mk urnaloba mozrdilebi 1500<br />

mozrdilebi 3<br />

fiziologiuri xsnaris CawveTeba,<br />

analgetiki/anti-<br />

miRebaze; bavSvebSi: 45 miRebaze;<br />

mg/dReSi 2 an 3<br />

g/dReSi 2 an 3<br />

SeniSvna piretiki, adgilobrivi <strong>da</strong>/an mg/kg/dReSi 2 an 3<br />

bavSvebSi: 90<br />

* p en ic xangrZlivoba oraluri il in ze Wedekongestatebi,<br />

Sm ar< it7-14 i aldReze<br />

er gi a: 7-10 miRebaze dRe (mozrdilebSi) an 10-14 dRe mg/kg/dReSi (bavSvebSi) 2 an gaumjobesebis<br />

• pen icilinze gareSe an ufro met xans miRebaze saSualo simZimis<br />

3<br />

urtikaria (antibiotikebi met anafilaqsia xans Tu ara gaumjobeseba<br />

aris) mwvave gamonayari an <strong>respiraciuli</strong><br />

simptomebi ar aris an WeSmariti<br />

mZime simptomatika, mudmivi • serozul-Cirqovani<br />

pen icilinze<br />

penicilinze efeqturia<br />

miuTuTebs WeSmarit alergiaze.<br />

makulopapuluri<br />

WeSmariti msubuqad infeqciis alergia aris dros Tu agamoxatuli<br />

na<strong>da</strong> mn ezar Si ax-<br />

il inzbaqteriuli e We Sm ar it i sinusitis<br />

al er gi a,<br />

azitromicini an<br />

alergia:*<br />

ar is gamonadeni alergia:* cxviri<strong>da</strong>n <strong>da</strong>/an xvela WeSmariti dRis saaTebSi<br />

pen icdens<br />

cef al os po riprevencias0<br />

ni s d an iS vn am de<br />

klaritromicini<br />

cefalosporini<br />

mii Re T Tu a le4- rg5 oldReSi og is kar on suiq ltna<br />

ac ia<br />

<strong>da</strong>/an<br />

an ifi qr eT re spir ac iu l<br />

fto rqga inumjobeseba, ol ze 1 8 we lzsaWiroa<br />

e me ti romelime mkurnaloba risk-faqtori un<strong>da</strong> saxezea asaki alergologis<br />

2 w-mde, aRzr<strong>da</strong><br />

ganme orebiTi<br />

40<br />

asa ki s pa ci en te bS i<br />

organizebul gagrZeldes koleqtivebSi, myari antibiotikebis konsultacia gamoyeneba<br />

** klavulanis komJavis nsultacia doza ar un<strong>da</strong> gaumjobeseba<br />

bolo gaumjobesebi<strong>da</strong>n<br />

ar aris<br />

3 Tvis manZilze 7 dRe<br />

48-72 saaTSi mxolod mudmivi<br />

gamonadeni ar aris mkurnalobis an morecidive Secvlis infeqcia.<br />

aRematebodes 10mg/kg/dReSi<br />

Cveneba

• ko-amoqsiklavi;<br />

• cefuroqsimi;<br />

• pen icilinze mwv ave otitis WeSmariti mar alergia:* Tvis <strong>respiraciuli</strong> ftorqinolini<br />

18 welze meti algoritmi<br />

asakis pacientebSi<br />

mkurnaloba un<strong>da</strong> gagrZeldes myari gaumjobesebi<strong>da</strong>n 7 dRe<br />

yuris mwvave infeqciis (yuris tkivili, cxeleba) an Sua<br />

yuri<strong>da</strong>n gamonadenis (<strong>da</strong>fis apkis hiperemia) niSnebi <strong>da</strong><br />

simptomebi<br />

mwvave S ua yuris an Teba<br />

1. gamonadenis arseboba (SeiniSneba gasinjvis dros an<br />

dgindeba pnevmaturi otoskopiiT)<br />

<strong>da</strong><br />

2. mwvave infeqciis niSnebi <strong>da</strong> simptomebi (yuris tkivili,<br />

cxeleba)<br />

tkivilis mkurnaloba<br />

risk faqtori: 2 wlamde asaki, bavSvi <strong>da</strong>dis baRSi<br />

an skolaSi, antibiotikis miReba bolo 3 TveSi<br />

Sua yuris anTeba<br />

gamonadeniT<br />

gamonadenis arseboba<br />

(SeiniSneba gasinjvis dros an<br />

dgindeba pnevmaturi<br />

otoskopiiT)<br />

mwvave infeqciis niSnebis <strong>da</strong><br />

simptomebis gareSe.<br />

antibiotiki ar aris naCvenebi,<br />

saWiroa <strong>da</strong>kvirveba 3 Tve<br />

ara<br />

• amoqsicilini:* 45 mg/kg/<br />

dReSi 2-3 miRebaze (Tu 2<br />

welze met asakSi <strong>da</strong>avadeba<br />

mZimed mimdina- reobs, saWiroa<br />

maRali doza - 90 mg/kg/ dReSi<br />

2-3 miRebaze)<br />

• pen icilinze WeSmariti<br />

referalis Cv en eba:<br />

otolaringologTan<br />

alergia:** cefalosporini<br />

• mastoiditis niSnebis arseboba;<br />

dia x<br />

• amoqsicilini:* 90 mg/kg/<br />

dReSi 2-3 miRebaze<br />

• pen icilinze WeSmariti<br />

alergia:**<br />

cefalosporini <strong>da</strong>/an<br />

alergologis<br />

konsultacia<br />

Tu gamonadenis<br />

xangrZlivoba > 3<br />

Tveze - saWiroa<br />

referali<br />

otolaringologTan,<br />

smenis Sefaseba<br />

mkurnaloba grZeldeba;<br />

• Tu simptomebi uaresdeba an ar umjobesdeba 2 dReSi.<br />

ganmeorebiTi konsultacia<br />

saWiroa 4-8 kviris<br />

SeniS vna<br />

*<br />

nev<br />

2 wlamde<br />

rologTan<br />

mkurnalobis xangrZlivoba 10 dRe, Tu 2 welis zemoT (Tu garTuleba ar aris), 5 dRe<br />

**• peni Tu cil gamoixata inz e<br />

Semdeg <strong>da</strong> gauaresebis<br />

aris WeSmar saxis<br />

gaumjobeseba iti nervis alergia: <strong>da</strong>zianebis<br />

2-3 WeSmarit dReSi<br />

simptomebi. alergiaze miuTiTebs urtikaria <strong>da</strong> anafilaqsia<br />

penicilinis SemTxvevaSi<br />

•<br />

audiologiuri mimarT.<br />

amoqsicilini: (mxolod gamonadeni<br />

gamokvleva makulo-papuluri<br />

90 mg/kg/ ar aris dReSi,<br />

saWiroa, gamonayari<br />

mkurnalobis ko-amoqsiklavi<br />

Tu ar miuTiTebs WeSmarit alergiaze. Tu alergia<br />

Secvlis *** 2-3 Cveneba) miRebaze 10 dRe. an : ceftriaqsoni 41<br />

gamoxatulia • cefalosporinis <strong>da</strong>niSvnamde, saWiroa alergologis konsultacia<br />

*** klavulonis kunTebSi <strong>da</strong>avadeba (pacientebSi, grZeldeba 3<br />

doza ar un<strong>da</strong> penicilinebis Tveze met xans<br />

aRematebodes autanlobis <strong>da</strong>/an Tu SeimCneva<br />

10 mg/kg/dReSiSemTxvevaSi).<br />

metyvelebis,<br />

di ax<br />

smenis <strong>da</strong>rRveva.<br />

• pen icilinze WeSmariti alergia** ara

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