Sinusitis: Difference between revisions
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== Background ==
== Background ==


#Acute (<4 weeks)
#Acute (&lt;4 weeks)  
##Acute viral
##Acute viral  
##Acute bacterial (0.5-2% of cases)
##Acute bacterial (0.5-2% of cases)  
#Subacute (4-12 weeks)
#Subacute (4-12 weeks)  
#Chronic (>12 weeks)
#Chronic (&gt;12 weeks)  
#Other causes
#Other causes  
##Fungal infections
##Fungal infections  
##Allergies
##Allergies


== Diagonsis ==
==Clinical Features==
#Defined as 2 or more of the following:
##Blockage or congestion of nose
##Facial pain or pressure
##Hyposmia (diminished ability to smell)
##Anterior or posterior nasal discharge lasting <12wk
#Additional symptoms:
##Tooth pain
##Fever
##Sinus pressure while bending forward to changing head position


{| width="437" border="1"
==Diagnosis==
|-
#Consider CT only for toxic pts (to r/o complication)
| style="width: 581px; height: 14px" colspan="3" width="437" valign="top" |
'''Classic History & Physical'''


|-
==DDX==
| style="width: 156px; height: 15px" width="117" | <center><br/></center>
#Migraine
| style="width: 87px; height: 15px" width="66" | <center>'''Viral'''</center>
#Craniofacial neoplasm
| style="width: 338px; height: 15px" width="254" | <center>'''Bacterial'''</center>
#Foreign body retention
|-
#Dental caries
| style="width: 156px; height: 15px" width="117" |
Duration (symptoms)


| style="width: 87px; height: 15px" width="66" | <center><10<span style="display: none; line-height: 0"></span>days</center>
== Treatment  ==
| style="width: 338px; height: 15px" width="254" | <center>Usually >10 days OR worsening symptoms within 10 days after initial improvement</center>
#<10 days of symptoms
|-
##Symptomatic treatment b/c most likely viral
| style="width: 156px; height: 29px" width="117" |
###Analgesia
Color change (nasal discharge)
###Mechanical irrigation with buffered, hypertonic saline
###Topical glucocorticoids
###Topical decongestants (e.g. oxymetazoline for no more than 3d)
###Antihistamines
###Mucolytics
#>10 days of symptoms OR if pt gets better and then worse again (“double sickening”)
##Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
###Another seven days of observation
##Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
###Consider amoxicillin
###Consider fluoroquinolone or amoxicillin-clavulanate if pt has had abx in past 4-6wks
#Antibiotic Failure
##Obtain culture
##Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
##Consider foreign body
##Consider fungal treatment


| style="width: 87px; height: 29px" rowspan="5" width="66" | <center>+/−</center>
==Complications==
| style="width: 338px; height: 29px" width="254" | <center>+++, quality usually yellow-green and thick</center>
#Meningitis
|-
#Cavernous sinus thrombosis
| style="width: 156px; height: 14px" width="117" |
#Intracranial abscess
Maxillary dental pain
#Orbital cellulitis
#Frontal bone osteomyelitis (Pott's puffy tumor)
#Extradural or subdural empyema


| style="width: 338px; height: 14px" width="254" | <center>+++, often unilateral and associated with a particular sinus</center>
== Source ==
|-
*UpToDate
| style="width: 156px; height: 14px" width="117" |
*Tintinalli
Postnasal drip


| style="width: 338px; height: 14px" width="254" | <center>More common</center>
[[Category:ID]]
|-
| style="width: 156px; height: 15px" width="117" |
Fever, cough, fatigue
 
| style="width: 338px; height: 15px" width="254" | <center>More common</center>
|-
| style="width: 156px; height: 14px" width="117" |
Hyposmia/anosmia
 
| style="width: 338px; height: 14px" width="254" | <center>More common</center>
|}
 
== Treatment ==
*1. <10 days of symptoms
**Symptomatic treatment b/c most likely viral
***Analgesia
***Mechanical irrigation with buffered, hypertonic saline
***Topical glucocorticoids
***Topical decongestants (e.g., oxymetazoline for no more than three days)
***Antihistamines
***Mucolytics
*2. >10 days or if pt gets better and then worse again (“double sickening”)
**Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
***Another seven days of observation
**Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
***Consider antibiotics
*If pt is immunocompromised, has underlying condition, or fails observation abx are indicated
*Obtain CT w/ contrast if concern for complications of sinusitis (e.g. postseptal cellulitis)
 
=== Antibiotics ===
#Choice depends on recent antibiotic therapy (past 4-6 weeks)
##Amoxicillin 80mg/kg/d x 10-14d
##Azithromycin 10mg/kg PO on day 1; then 5mg/kg QD x 5-7d
##Cefpodoxime
##Cefdinir
##Cefuroxime
 
=== Antibiotic Failure ===
*If initial abx failure occurs consider further workup (e.g. CT) and/or further tx w/ amoxicillin-clavulanate or respiratory fluoroquinolone
*Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation)
**Associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
*Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis
 
==Source==
 
UpToDate
 
Tintinalli
 
[[Category:ID]] <br/>

Revision as of 20:51, 7 November 2011

Background

  1. Acute (<4 weeks)
    1. Acute viral
    2. Acute bacterial (0.5-2% of cases)
  2. Subacute (4-12 weeks)
  3. Chronic (>12 weeks)
  4. Other causes
    1. Fungal infections
    2. Allergies

Clinical Features

  1. Defined as 2 or more of the following:
    1. Blockage or congestion of nose
    2. Facial pain or pressure
    3. Hyposmia (diminished ability to smell)
    4. Anterior or posterior nasal discharge lasting <12wk
  2. Additional symptoms:
    1. Tooth pain
    2. Fever
    3. Sinus pressure while bending forward to changing head position

Diagnosis

  1. Consider CT only for toxic pts (to r/o complication)

DDX

  1. Migraine
  2. Craniofacial neoplasm
  3. Foreign body retention
  4. Dental caries

Treatment

  1. <10 days of symptoms
    1. Symptomatic treatment b/c most likely viral
      1. Analgesia
      2. Mechanical irrigation with buffered, hypertonic saline
      3. Topical glucocorticoids
      4. Topical decongestants (e.g. oxymetazoline for no more than 3d)
      5. Antihistamines
      6. Mucolytics
  2. >10 days of symptoms OR if pt gets better and then worse again (“double sickening”)
    1. Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
      1. Another seven days of observation
    2. Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
      1. Consider amoxicillin
      2. Consider fluoroquinolone or amoxicillin-clavulanate if pt has had abx in past 4-6wks
  3. Antibiotic Failure
    1. Obtain culture
    2. Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
    3. Consider foreign body
    4. Consider fungal treatment

Complications

  1. Meningitis
  2. Cavernous sinus thrombosis
  3. Intracranial abscess
  4. Orbital cellulitis
  5. Frontal bone osteomyelitis (Pott's puffy tumor)
  6. Extradural or subdural empyema

Source

  • UpToDate
  • Tintinalli
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