Sinusitis: Difference between revisions
 
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==Background==
==Background==
[[File:Paranasal sinuses numbers.png|thumb|Paranasal sinuses: 1. frontal sinuses, 2. ethmoid sinuses (ethmoidal air cells), 3. sphenoid sinuses, 4. maxillary sinuses.]]
*Viral source is by far most common. Bacterial infection accounts for only 0.5-2% of all cases<ref name="Fokkens">Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar;(23):3 p preceding table of contents, 1-298</ref>
**Other causes include allergies and fungal infection
*Timeframe
**Acute (<4 weeks)
**Subacute (4-12 weeks)
**Chronic (>12 weeks)


Rhinosinusitis - Inflammation of the lining of the paranasal sinuses
==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


#Acute (< 4 weeks)
===Clinical Features of Bacterial Sinusitis===
##Acute viral
*Symptoms persist >10 days
##Acute bacterial (0.5-2% of cases)
*Daytime [[cough]]
#Subacute (4-12 weeks)
*Worsening or bimodal course
#Chronic (>12 weeks)
*Fever >102.2F (39C)
#Other causes
*Purulent nasal discharge >3d
##Fungal infections
*Pain in maxillary teeth
##Allergies
*Hx of diabetes


==Diagonsis==
==Clinical Features of Fungal Sinusitis==
*Seen most often in immunocompromised individuals and poorly controlled diabetics
*Presents similarly to viral and bacterial sinusitis but symptoms worsen over time and do not improve with antibiotics
*See [[Mucormycosis]]


{| style="width: 581px; width="437" border="1"
==Differential Diagnosis==
| style="width: 581px; height: 14px" colspan="3" width="437" valign="top" |
{{Rhinorrhea}}
'''Classic History & Physical'''
|-
| style="width: 156px; height: 15px" width="117" |
<center>'''Feature'''</center>
| style="width: 87px; height: 15px" width="66" |
<center>'''Viral'''</center>
| style="width: 338px; height: 15px" width="254" |
<center>'''Bacterial'''</center>
|-
| 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>
| style="width: 338px; height: 15px" width="254" |
<center>Usually >10 days OR worsening symptoms within 10 days after initial improvement</center>
|-
| style="width: 156px; height: 29px" width="117" |
Color change (nasal discharge)
| style="width: 87px; height: 29px" rowspan="5" width="66" |
<center>+/−</center>
| style="width: 338px; height: 29px" width="254" |
<center>+++, quality usually yellow-green and thick</center>
|-
| style="width: 156px; height: 14px" width="117" |
Maxillary dental pain
| style="width: 338px; height: 14px" width="254" |
<center>+++, often unilateral and associated with a particular sinus</center>
|-
| style="width: 156px; height: 14px" width="117" |
Postnasal drip
| style="width: 338px; height: 14px" width="254" |
<center>More common</center>
|-
| 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==
{{Headache DDX}}
#< 10 days 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
#10 days or if pt gets better and then worse again (“double sickening”)
##Mild bacterial sinusitis when pain is mild and temperature < 38.3˚C
##Another seven days of observation
##Severe bacterial sinusitis when pain is moderate-severe or temperature ≥38.3˚C
##Consider antibiotics
##If the patient is immunocompromised, has an underlying or complicating condition, or patient fails observation, antibiotics are indicated


===Antibiotics===
==Evaluation==
#Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
[[File:Ethmoidinfection.png|thumb|A CT scan showing sinusitis of the ethmoid sinus.]]
##Amoxicillin (500mg PO TID for 10 days)
[[File:FrontalSinusitisMark.png|thumb|A CT scan showing sinusitis of the frontal sinus.]]
##TMP-SMX
[[File:RtmaxobitinfectteethCT.png|thumb|Maxillary sinusitis caused by a dental infection associated with [[periorbital cellulitis]].]]
##Erythromycin
[[File:Sinuses and Sinusitis (5937085231).jpg|thumb|CT finding of chronic sinusitis.]]
##Azithromycin
*Clinical diagnosis
##Cefpodoxime
*Consider CT only for toxic patients (to rule-out complication)
##Cefdinir
 
##Cefuroxime
===IDSA Guidelines 2012<ref>Chow AW et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Disease (2012) 54:e72-112.</ref>===
*Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
*Concern for bacterial (treat with antibiotics) if any of these:
**Purulent discharge and pain on face or teeth > 10 days without improvement
**Severe symptoms or fever > 39 plus symptoms > 3 days
**"Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days
 
==Management==
===<10 days of symptoms===
*Symptomatic treatment:
**[[Analgesia]]
**Mechanical irrigation with buffered, hypertonic saline
**OTC decongestants
**Intranasal decongestants (e.g. [[oxymetazoline]] for no more than 3 days)
**Intranasal corticosteroids (e.g. [[mometasone furoate]] monohydrate, [[Flonase]])<ref>Trestioreanu AZ, Yaphe J. "Intranasal steroids for acute sinusitis." The Cochrane Database of Systematic Reviews. 2 December 2013. DOI: 10.1002/14651858.CD005149.pub4</ref>
*Avoid antibiotics (Part of [[Choosing wisely ACEP|ACEP Choosing wisely]])
 
===>10 days of symptoms===
*Possible bacterial source, especially if associated with:
**No clinical improvement after 10 days
**Severe symptoms or high fever and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness
**Onset with newly worsening that were initially improving (‘‘doublesickening’’)
*Acute bacterial sinusitis<ref>Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. IDSA Guidelines. 2012; Clinical Infectious Diseases e1-e41.</ref>
**Strep pneumo, non-typeable H. flu, Moraxella
**First line is [[amoxicillin-clavulanate]] for 7-10 days
***Amox 40-45mg/kg PO with clavulanate 3.2 mg/kg PO bid for 10d
**Second line is a respiratory [[fluoroquinolones]] ([[moxifloxacin]], [[gemifloxacin]], and [[levofloxacin]]) or [[doxycycline]]
**If allergic, can use [[cefdinir]] (7mg/kg PO bid) or [[cefuroxime]] (15 mg/kg PO bid)


===Antibiotic Failure===
===Antibiotic Failure===
#If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone
*Obtain culture
#Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation) and often is associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
#Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis
*Consider [[foreign body]]
*Consider [[antifungals]]
 
==Disposition==
*Discharge
 
==Complications==
*[[Meningitis]]
*[[Cavernous sinus thrombosis]] (ethmoid/sphenoid)
*[[Intracranial abscess]]
*[[Orbital cellulitis]] (ethmoid)
*[[Frontal bone osteomyelitis]] (Pott's puffy tumor)
*Extradural or subdural empyema


== Source ==
==See Also==
*[[Headache]]


DeBonis, Kaji, UpToDate "Rhinosinusitis"
==References==
<references/>


<br/>[[Category:ID]]
[[Category:ID]]

Latest revision as of 17:58, 11 December 2021

Background

Paranasal sinuses: 1. frontal sinuses, 2. ethmoid sinuses (ethmoidal air cells), 3. sphenoid sinuses, 4. maxillary sinuses.
  • Viral source is by far most common. Bacterial infection accounts for only 0.5-2% of all cases[1]
    • Other causes include allergies and fungal infection
  • Timeframe
    • Acute (<4 weeks)
    • Subacute (4-12 weeks)
    • Chronic (>12 weeks)

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

Clinical Features of Bacterial Sinusitis

  • Symptoms persist >10 days
  • Daytime cough
  • Worsening or bimodal course
  • Fever >102.2F (39C)
  • Purulent nasal discharge >3d
  • Pain in maxillary teeth
  • Hx of diabetes

Clinical Features of Fungal Sinusitis

  • Seen most often in immunocompromised individuals and poorly controlled diabetics
  • Presents similarly to viral and bacterial sinusitis but symptoms worsen over time and do not improve with antibiotics
  • See Mucormycosis

Differential Diagnosis

Rhinorrhea

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

A CT scan showing sinusitis of the ethmoid sinus.
A CT scan showing sinusitis of the frontal sinus.
Maxillary sinusitis caused by a dental infection associated with periorbital cellulitis.
CT finding of chronic sinusitis.
  • Clinical diagnosis
  • Consider CT only for toxic patients (to rule-out complication)

IDSA Guidelines 2012[2]

  • Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
  • Concern for bacterial (treat with antibiotics) if any of these:
    • Purulent discharge and pain on face or teeth > 10 days without improvement
    • Severe symptoms or fever > 39 plus symptoms > 3 days
    • "Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days

Management

<10 days of symptoms

>10 days of symptoms

  • Possible bacterial source, especially if associated with:
    • No clinical improvement after 10 days
    • Severe symptoms or high fever and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness
    • Onset with newly worsening that were initially improving (‘‘doublesickening’’)
  • Acute bacterial sinusitis[4]

Antibiotic Failure

  • Obtain culture
  • Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
  • Consider foreign body
  • Consider antifungals

Disposition

  • Discharge

Complications

See Also

References

  1. ↑ Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar;(23):3 p preceding table of contents, 1-298
  2. ↑ Chow AW et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Disease (2012) 54:e72-112.
  3. ↑ Trestioreanu AZ, Yaphe J. "Intranasal steroids for acute sinusitis." The Cochrane Database of Systematic Reviews. 2 December 2013. DOI: 10.1002/14651858.CD005149.pub4
  4. ↑ Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. IDSA Guidelines. 2012; Clinical Infectious Diseases e1-e41.
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