Terms of Use: Ann Int Med. 152 (9) : ITC5-1

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Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1.
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in the clinic
Acute Sinusitis
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)
What factors increase the risk for acute sinusitis?

Most common: Recent viral URI or allergies Cystic fibrosis Immune deficiency (AIDS, poorly controlled diabetes) risk fungal invasive sinusitis Autoimmune disease (Wegener granulomatosis) Facial injury or structural abnormality deviated septum, nasal polyp Pregnancy Hospitalization (Abx or steroid Rxs, NG or ET tubes)
How can patients decrease their risk for acute sinusitis?

Frequent hand-washing Nasal corticosteroids, immunotherapy (prevent recurrent sinusitis in allergic persons) Decongestant nose drops (before air travel) Humidifier, steam inhalation, nasal irrigation
Avoid sick contacts

Avoid allergens, irritants (smoke, chemicals, strong odors)
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)
What is the role of the history and physical exam in the diagnosis of acute sinusitis?
Primary Symptoms: Purulent rhinitis & facial pain (esp combo)
Other Signs & Symptoms

Nasal congestion or obstructuction Postnasal drainage
Check for:
Swollen turbinates Purulent rhinorrhea Nasal polyps Sinus pain if bending over Oropharyngeal red streak Ask about:
Hyposmia or anosmia
Ear pressure Cough Worsening symptoms after initial improvement
Allergies & other risk factors

Symptom duration (<10 days unlikely bacterial)
Why is it important to distinguish acute sinusitis from chronic sinusitis?

Acute Cause: usually viral URI Duration: 1 - <4 wks Typically more severe Chronic Cause: inflammation & blockage (allergies, septal deviation, polyps, tumors, foreign body) Duration: t >4 wks- years
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)
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)
What is the role of imaging in the diagnosis of acute sinusitis?

Imaging not routinely required or appropriate Not cost-effective c/w symptomatic Rx or criteria-guided Abx Xray evidence sinusitis in 87% viral URIs But <3% progress to bacterial infection
What is the role of imaging in the diagnosis of acute sinusitis? Occipitomental view
Consider Xray :
Sxs 7-10 d + Non-response/recur w/Rx (Waters): Standard for paranasal sinuses, esp maxillary
Other conditions seriously considered

Risk of complications (e.g., immunocompromised) Possible atypical microbe (e.g., Pseudomonas aeruginosa, or fungal infection w/ immunocompromise)
3 or 4 often ordered
Positive radiographs: Sinus fluid/opacity Mucous membrane thickening >50%
Consider CT/MRI :
Possible local spread or intracranial complications
Symptoms persist >3 wks despite Rx or recur
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 passage Alternative: 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
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
What organisms can cause acute sinusitis?

Predominant isolates (>50% acute bacterial sinusitis) Streptococcus pneumonia Haemophilus influenzae
Other bacteria: Moraxella catarrhalis (esp children & young adults) and Streptococcus pyogenes
~ H. influenzae most M. catarrhalis resistant to Acute fungal sinusitis & (less common) penicillin/amoxicillin Aspergillus Production -lactamase (H. influenzae, M. catarrhalis, Staphylococcus aureus, Fusobacterium spp., and Mucor Prevotella spp.) or Usually occur in immunocompromised Changes in penicillin-binding protein (S. pneumoniae) Fulminant invasive disease high mortality if not treated w/ more resistant bacteria often need antimicrobial Tx early,Pts aggressively (nasal surgery) directed at all pathogens in mixed infections
What nondrug measures are helpful in the treatment of patients with acute sinusitis?
Steam inhalation Hydration Sinus irrigation (e.g, neti pot) Increase mucosal moisture, thin mucus, aid sinus drainage Remove inflammatory debris & bacteria How to Perform Nasal Irrigation Salt-water solution: 1/2 tsp noniodinated salt 1/2 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
How should clinicians decide whether to use antibiotics to treat acute sinusitis?
Antibiotic therapy appropriate if: High probability bacterial sinusitis Symptomatic Rx fails in low-probability patients Probability of Bacterial Sinusitis 2: high probability (>50%) < 1: low probability (<25%) URI >7 days facial pain purulent discharge (nasal, pharyngeal, or both)
Choice of Abx determined by circumstances Increased pneumococcal resistance to macrolides Trimethoprimsulfamethoxazole 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
Amoxicillin 1st line agent Doxycycline noif improvement afteror 3-5 d, consider If Use penicillin allergy persistent symptoms Trimethoprim sulfamethoxazole alternative Abx Broader spectrum than amoxicillin Cephalosporins Use if: AEs: rash, GI symptoms, hypersensitivity Covers -lactamase producing strains H. Penicillin allergy or persistent symptoms reaction (rare) nd-line use (1st 2nd -generation (cefpodoxime) for 2 influenzae, M. catarrhalis Pneumococcal resistance 24% generation minimal efficacy against S. pneumoniae, AEs: Not for GIchildren upset, neutropenia, photosensitivity, H. influenzae) not No recd improvement in children after 8 y3-5 d, consider alternative Caution if penicillin allergy antibiotic AEs: GI upset, headache, rash, blood dyscrasias AEs: rash, GI symptoms, hematologic (rare), toxic epidermal necrolysis (rare)
How should clinicians decide whether to use other drugs to treat acute sinusitis?
Nasal steriods Reduces mucosalbacterial inflammation Initial therapy in pts w/ low probability disease (fluticasone) May cause local irritation
Relieve symptoms For severe disease, reduces pain Oral corticosteroids

Oral antihistamines environment Anti-inflammatory, helpful with allergic Restore normal sinus and function (loratadine) rhinitis
Efficacy varies, evidence limited Nasal decongestant Anti-inflammatory, vasoconstriction(xylometazoline) improves ostial drainage Avoid use for 3-5 d risk for rebound congestion Caution if CVD, poorly controlled hypertension, hyperthyroidism, diabetes mellitus Reduces viscosity of nasal secretions May cause GI symptoms
Systemic decongestants (pseudoephedrine) Mucolytic agents (guaifenesin)
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
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
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
Do special considerations exist for care of patients with recurrent acute sinusitis?
Can be difficult to determine: Does recurrence represent relapse or de novo episode?
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
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
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 OtolaryngologyHead 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

Terms of Use: Ann Int Med. 152 (9) : ITC5-1

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Terms of Use: Ann Int Med. 152 (9) : ITC5-1

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* For Best Viewing:

relevant text from ITC in the notes pages of each slide

What factors increase the risk for acute sinusitis?

What factors increase the risk for acute sinusitis?

How can patients decrease their risk for acute sinusitis?

Avoid sick contacts

Other Signs & Symptoms

Allergies & other risk factors

Why is it important to distinguish acute sinusitis from chronic sinusitis?

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

Other conditions seriously considered

Symptoms persist >3 wks despite Rx or recur

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

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

CBC w/with differential

What organisms can cause acute sinusitis?

Relieve symptoms For severe disease, reduces pain Oral corticosteroids

Systemic decongestants (pseudoephedrine) Mucolytic agents (guaifenesin)

What are complications of acute sinusitis?

Nerve injury: Permanent loss of smell or taste

What are complications of acute sinusitis?

Orbital swelling, conjunctival erythema, limited extraocular movements

When should clinicians consult a specialist?

Are there practice guidelines relevant to acute sinusitis?

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

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