Sinusitis

Background

Rhinosinusitis - Inflammation of the lining of the paranasal sinuses

Acute (< 4 weeks)

• Acute viral
• Acute bacterial (0.5-2% of cases)

Subacute (4-12 weeks)

Chronic (>12 weeks)

Other causes

• Fungal infections
• Allergies

Diagonsis

Classic History & Physical
Feature	Viral	Bacterial
Duration (symptoms)	<10days	Usually >10 days OR worsening symptoms within 10 days after initial improvement
Color change (nasal discharge)	+/−	+++, quality usually yellow-green and thick
Maxillary dental pain		+++, often unilateral and associated with a particular sinus
Postnasal drip		More common
Fever, cough, fatigue		More common
Hyposmia/anosmia		More common

Basic Management

< 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

• Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
  • Amoxicillin (500mg PO TID for 10 days)
  • TMP-SMX
  • Erythromycin
  • Azithromycin
  • Cefpodoxime
• Cefdinir
• Cefuroxime
  • If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone
  • 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
  • Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis==Source==DeBonis, Kaji, UpToDate "Rhinosinusitis"
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Background

Rhinosinusitis - Inflammation of the lining of the paranasal sinuses

Acute (< 4 weeks)

• Acute viral
• Acute bacterial (0.5-2% of cases)

Subacute (4-12 weeks)

Chronic (>12 weeks)

Other causes

• Fungal infections
• Allergies

Diagonsis

Classic History & Physical

Feature

Viral

Bacterial

Duration (symptoms)

<10days

Usually >10 days OR worsening symptoms within 10 days after initial improvement

Color change (nasal discharge)

+/−

+++, quality usually yellow-green and thick

Maxillary dental pain

+++, often unilateral and associated with a particular sinus

Postnasal drip

More common

Fever, cough, fatigue

More common

Hyposmia/anosmia

More common

Basic Management

< 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

• Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
• Amoxicillin (500mg PO TID for 10 days)
• TMP-SMX
• Erythromycin
• Azithromycin
• Cefpodoxime

* Cefdinir * Cefuroxime



• If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone

• 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

• Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis

Source

DeBonis, Kaji, UpToDate "Rhinosinusitis"