Acute sinusitis

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

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© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

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© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

in the clinic

Acute Sinusitis

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What factors increase the risk for acute sinusitis?Most common: Recent viral URI or allergies

Asthma (Triad: asthma, nasal polyps, ASA intolerance)

Age (old: immunity, URI, dry/weak nasal cartilage)

Environmental irritants (smoke, chlorine)

Atmospheric pressure changes (air travel)

Dental/periodontal infection or sinus perforation during tooth extraction

Kartagener syndrome (sinusitis, bronchiectasis, dextrocardia)

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What factors increase the risk for acute sinusitis?

Most common: Recent viral URI or allergies

Immune deficiency (AIDS, poorly controlled diabetes)

risk fungal invasive sinusitis

Cystic fibrosis

Autoimmune disease (Wegener granulomatosis)

Hospitalization (Abx or steroid Rxs, NG or ET tubes)

Pregnancy

Facial injury or structural abnormality

deviated septum, nasal polyp

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

How can patients decrease their risk for acute sinusitis?

Frequent hand-washing

Avoid sick contacts

Avoid allergens, irritants (smoke, chemicals, strong odors)

Nasal corticosteroids, immunotherapy (prevent recurrent sinusitis in allergic persons)

Decongestant nose drops (before air travel)

Humidifier, steam inhalation, nasal irrigation

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of the history and physical exam in the diagnosis of acute sinusitis?

H&P Basis for diagnosis

No accepted office-based test

Gold-standard: culture aspirate from antral puncture (Not routine painful, risks, requires expertise)

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of the history and physical exam in the diagnosis of acute sinusitis?

Other Signs & Symptoms

Nasal congestion or obstructuction

Postnasal drainage

Hyposmia or anosmia

Ear pressure

Cough

Worsening symptoms after initial improvement

Check for:

Swollen turbinates

Purulent rhinorrhea

Nasal polyps

Sinus pain if bending over

Oropharyngeal red streak

Primary Symptoms: Purulent rhinitis & facial pain (esp combo)

Ask about:

Allergies & other risk factors

Symptom duration (<10 days unlikely bacterial)

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

Why is it important to distinguish acute sinusitis from chronic sinusitis?Acute Cause: usually viral URI Duration: 1 - <4 wks Typically more severe

Chronic sinusitis

•Poor response to usual Abx Rx

•Longer Rx often needed

•Surgery if refractory to medical Rx

•Acute exacerbations Poorer response: severe allergies, structural changes from chronic sinusitis itself or prior surgery)

Chronic Cause: inflammation & blockage

(allergies, septal deviation, polyps, tumors, foreign body)

Duration: t >4 wks- years

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What noninfectious conditions should clinicians consider when evaluating for acute sinusitis?

Allergic rhinitis

Drug-induced rhinitis (decongestant use >5 d, cocaine)

Recurrent viral URIs

Dental pain

Chronic sinusitis if symptom duration > 12 wks

distinct differential dx

Occupational rhinosinusitis

Gastroesophageal reflux

Migraine/tension headache

Nasal polyps (obstruction)

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of imaging in the diagnosis of acute sinusitis?

Imaging not routinely required or appropriate

Xray evidence “sinusitis” in 87% viral URIs

But <3% progress to bacterial infection

Not cost-effective c/w symptomatic Rx or criteria-guided Abx

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of imaging in the diagnosis of acute sinusitis?

Consider Xray : Sxs ≥ 7-10 d + Non-response/recur w/Rx Other conditions seriously considered Risk of complications (e.g., immunocompromised) Possible atypical microbe (e.g., Pseudomonas aeruginosa, or

fungal infection w/ immunocompromise)

Consider CT/MRI : Possible local spread or intracranial complications Symptoms persist >3 wks despite Rx or recur

Occipitomental view (Waters): Standard for paranasal sinuses, esp maxillary 3 or 4 often ordered

Positive radiographs: Sinus fluid/opacity Mucous membrane thickening >50%

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of laboratory testing in the diagnosis of acute sinusitis? Usually NOT needed

If Rx non-response or worsening symptom: culture

Gold standard: Sinus puncture (maxillary) Invasive, risk of pain, bleeding, swelling, false passageAlternative: Transnasal endoscopic culture Requires ENT: topical anesthetic, less invasive Nasal swab / culture (direct swab thru nose) Poor correlation w/sinus pathogens Contamination w/normal nasal flora

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What is the role of laboratory testing in the diagnosis of acute sinusitis?

Other lab tests: depend on clinical situation

CBC w/with differential

TFT for fatigue

Chloride testing for CF

If sinusitis recurrent/persistent refer for evaluation of allergy/immune deficiency

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What organisms can cause acute sinusitis?

~⅓ H. influenzae & most M. catarrhalis resistant to penicillin/amoxicillin Production β-lactamase (H. influenzae, M. catarrhalis, Staphylococcus aureus, Fusobacterium spp., and Prevotella spp.) or Changes in penicillin-binding protein (S. pneumoniae)

Pts w/ more resistant bacteria often need antimicrobial Tx directed at all pathogens in mixed infections

Predominant isolates (>50% acute bacterial sinusitis)

Streptococcus pneumonia Haemophilus influenzae

Other bacteria: Moraxella catarrhalis (esp children & young adults) and Streptococcus pyogenes

Acute fungal sinusitis (less common)

AspergillusMucor

Usually occur in immunocompromised

Fulminant invasive disease high mortality if not treated early, aggressively (nasal surgery)

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What nondrug measures are helpful in the treatment of patients with acute sinusitis?

Steam inhalation

Hydration

Sinus irrigation (e.g, neti pot)

How to Perform Nasal Irrigation

Salt-water solution: 1/2 tsp noniodinated salt1/2 tsp baking soda 8-oz warm water

Place in delivery device (e.g., neti pot, bulb syringe)

Lean over sink, head down, chin up

Pour/squeeze water gently in upper nostril (drains out other nostril)

Repeat on other side

Increase mucosal moisture, thin mucus, aid sinus drainage

Remove inflammatory debris & bacteria

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

How should clinicians decide whether to use antibiotics to treat acute sinusitis?

Probability of Bacterial Sinusitis ≥ 2: high probability (>50%) < 1: low probability (<25%)URI >7 daysfacial painpurulent discharge (nasal, pharyngeal, or both)

Antibiotic therapy appropriate if: High probability bacterial sinusitis Symptomatic Rx fails in low-probability patients

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

How should clinicians decide whether to use antibiotics to treat acute sinusitis?

Choice of Abx determined by circumstances

Increased pneumococcal resistance to macrolides

Trimethoprim–sulfamethoxazole acceptable 1st-line agent in adults, but not recommended in children

Broad-spectrum agents usually not necessary for 1st-line Rx

Cephalosporins

Fluoroquinolones

More costly Concern promoting resistance among bacteria in community & host

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

How should clinicians decide whether to use antibiotics to treat acute sinusitis?

Amoxicillin 1st line agent If no improvement after 3-5 d, consider alternative Abx AEs: rash, GI symptoms, hypersensitivity reaction (rare)

Use if penicillin allergy or persistent symptoms Broader spectrum than amoxicillin Covers β-lactamase–producing strains H. influenzae, M. catarrhalis AEs: GI upset, neutropenia, photosensitivity, not rec’d in children ≤8 y

Use if:• Penicillin allergy or persistent symptoms• Pneumococcal resistance ≥24%

Not for children No improvement after 3-5 d, consider alternative antibiotic AEs: rash, GI symptoms, hematologic (rare), toxic epidermal necrolysis (rare)

2nd-generation (cefpodoxime) for 2nd-line use (1st-generation minimal efficacy against S. pneumoniae, H. influenzae) Caution if penicillin allergy AEs: GI upset, headache, rash, blood dyscrasias

Doxycycline

Trimethoprim–sulfamethoxazole

Cephalosporins

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

How should clinicians decide whether to use other drugs to treat acute sinusitis?

Nasal steriods (fluticasone)

Reduces mucosal inflammation May cause local irritation

Oral corticosteroids For severe disease, reduces pain

Oral antihistamines (loratadine)

Anti-inflammatory, helpful with allergic rhinitis

Nasal decongestant (xylometazoline)

Anti-inflammatory, vasoconstriction- improves ostial drainage Avoid use for ≥3-5 d risk for rebound congestion

Systemic decongestants (pseudoephedrine)

Caution if CVD, poorly controlled hypertension, hyperthyroidism, diabetes mellitus

Mucolytic agents (guaifenesin)

Reduces viscosity of nasal secretions May cause GI symptoms

Initial therapy in pts w/ low probability bacterial disease

Relieve symptoms

Restore normal sinus environment and function

Efficacy varies, evidence limited

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What are complications of acute sinusitis?

Serious complications rare when managed properly

Proximity of sinuses to CNS infection can become life threatening if spreads: may require CT for Dx

Intracranial: Extension into ostial/meningeal structures (abscess)

Orbital/Periorbital cellulitis: Orbital extension (inflammation, abscess, blindness)

Aneurysm/blood clot: Extension from sphenoid sinus to carotid artery or cavernous sinus (may be fatal)

Nerve injury: Permanent loss of smell or taste

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

What are complications of acute sinusitis?

Clinical alerts

Orbital swelling, conjunctival erythema, limited extraocular movements

Focal neurologic signs

Altered mental status

Abnormal culture on sinus puncture

Exacerbation of asthma

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

When should clinicians consult a specialist?

Complicated patients, severe symptoms, or nonresponsive to initial therapy

Otolaryngologist: When nonresponse to initial Rx or sinus recurrent/chronic infections, or if anatomical abnormality suspected

Allergist: Underlying atopic disease, recurrent sinus infections or symptoms persistent; treating sinus condition improves asthma

May require ophthalmologist, neurosurgeon, ID expert, or neurologist, depending on symptoms

Hospitalize with serious complications: orbital involvement, infection or thrombosis of the intracranial venous sinuses, or metastatic spread to CNS

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

Do special considerations exist for care of patients with recurrent acute sinusitis?

Reevaluate when Symptoms persist wks New or worsening symptoms

Failure to improve may indicate Antibiotic resistance Significant allergic inflammation Fungal infection (rather than bacterial) Presence of complications

Can be difficult to determine: Does recurrence represent relapse or de novo episode?

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

Do special considerations exist for care of patients with recurrent acute sinusitis?

Check for:Persistent fever, sinus tenderness, purulent discharge, change in mental status/vision

Assess factors that could modify Rx:Allergic rhinitis, anatomical variation, CF, ciliary dyskinesia, immune compromise

Imaging studies & bacterial cultures:May guide Rx course & assess ? complications

If no anatomical anomalies upon evaluation: Try 2nd-line antibiotic therapy

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

© Copyright Annals of Internal Medicine, 2010Ann Int Med. 152 (9): ITC5-1.

Are there practice guidelines relevant to acute sinusitis? Joint Council of Allergy, Asthma, and Immunology

(2005): fungi factor in chronic sinusitis

American College of Chest Physicians (2006): Make no dx in 1st wk symptoms

American Academy of Otolaryngology—Head and Neck Surgery Foundation (2007): Consider other causes, complications when worse or no improvement 7 d after dx and mgmt

British National Institute for Health and Clinical Excellence (2008): Use “No antibiotic or delayed antibiotic strategy" for most

Agency for Healthcare Research and Quality (2005): Few studies compare efficacy newer antibiotics w/older, less expensive ones