RHINOSINUSITIS

RHINOSINUSITIS

Current Diagnos

• Since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa, rhinosinusitis is a more accurate term for what is commonly called sinusitis.

• Most cases of sinusitis are caused by viral infections associated with the common cold. Viral rhinosinusitis improves in 7 to 10 days.

• Four signs and symptoms with a high likelihood ratio for acute bacterial sinusitis are double sickening, purulent rhinorrhea, erythrocyte sedimentation rate (ESR) greater than 10 mm, and purulent secretion in the nasal cavity. A combination of at least three of these four symptoms and signs has a specificity of 0.81 and sensitivity of 0.66 for acute bacterial rhinosinusitis.

• Acute rhinosinusitis lasts up to 4 weeks, subacute rhinosinusitis lasts from 4 to 12 weeks, and chronic rhinosinusitis lasts 12 weeks or longer. Recurrent acute rhinosinusitis is defined as four or more episodes per year with complete resolution between episodes.

• Radiographic imaging in a patient with acute rhinosinusitis is not recommended unless a complication or an alternative diagnosis is suspected. Computed tomography of the sinuses without contrast media is the imaging method of choice.

Current Therapy

• Mild rhinosinusitis symptoms less than 7 days’ duration can be managed with supportive care including analgesics, saline nasal irrigation, and intranasal corticosteroids.

• Antibiotic therapy is recommended for patients with sinusitis symptoms that do not improve within 7 to 10 days or that worsen at any time.

• First-line antibiotics include amoxicillin with or without clavulanate.

• Macrolides and trimethoprim sulfamethoxazole (Bactrim) are not recommended for empiric therapy owing to high rates of resistance among Streptococcus pneumoniae and Haemophilus influenzae.

• For adults allergic to penicillin, doxycycline may be used as an alternative regimen for initial empiric therapy for bacterial rhinosinusitis. According to a recent U.S. Food and Drug Administration (FDA) safety alert, fluoroquinolones such as levofloxacin (Levaquin) and moxifloxacin (Avelox) should be reserved for patients who do not have other treatment options.

• In adults with confirmed acute rhinosinusitis, more than 70% will clinically improve after 2 weeks with or without antibiotic therapy.

• Antibiotic use increases the absolute cure rate by 5% compared with placebo at 7 to 15 days.

Epidemiology of Acute Rhinosinusitis and Predisposing Factors

Each year in the United States, rhinosinusitis affects one in seven adults and is diagnosed in 31 million patients. Rhinosinusitis is the fifth most common diagnosis for which antibiotics are prescribed. Rhinosinusitis has a higher frequency in the winter months and lower frequency in the summer and autumn months.

Predisposing Factors

Predisposing factors for acute rhinosinusitis include viral upper respiratory infections and allergic rhinitis. Anatomic malformations including polyps, deviated nasal septum, foreign bodies, and tumors can also predispose to acute rhinosinusitis.

Pathogenesis and Etiology of Rhinosinusitis

Most cases of acute rhinosinusitis are caused by viral infections associated with the common cold. The most common viruses in acute viral rhinosinusitis are rhinovirus, adenovirus, influenza virus, and parainfluenza virus. Mucosal edema occurs with the viral infection with subsequent obstruction of the sinus ostia. In addition, viral and bacterial infections impair the cilia, which help transport the mucus. The ostia obstruction and slowed mucus transport cause stagnation of secretions and lowered oxygen tension within the sinuses. This environment is an excellent culture medium for both viruses and bacteria and the infectious particles grow rapidly. The body responds with an inflammatory reaction. Polymorphonuclear leukocytes are mobilized, which results in pus formation. The most common bacteria found in acute community-acquired bacterial rhinosinusitis are S. pneumoniae, H. influenzae, Staphylococcus aureus, and Moraxella catarrhalis. Acute adult rhinosinusitis most commonly involves the maxillary and ethmoid sinuses. More than one of the paranasal sinuses can be effected.

Diagnosis of Acute Rhinosinusitis

Diagnosis of acute bacterial rhinosinusitis requires that symptoms persist for longer than 10 days or worsen after 5 to 7 days. Four signs and symptoms with a high likelihood ratio for acute bacterial sinusitis are double sickening, purulent rhinorrhea, ESR greater than 10 mm, and purulent secretion in the nasal cavity. A combination of at least three of these four symptoms and signs has a specificity of 0.81 and sensitivity of 0.66 for acute bacterial rhinosinusitis. Table 1 lists the sensitivity, specificity, likelihood ratio, and odds ratio of criteria used to diagnose acute rhinosinusitis. If resistant pathogens are suspected or if the patient’s immune system is compromised, bacterial culture of the secretions may be used for diagnosis and to direct therapy.

Table 1

Signs and Symptoms of Acute Bacterial Rhinosinusitis

 

• No data given in reference

Imaging

For uncomplicated acute rhinosinusitis, radiographic imaging is not recommended. Plain sinus radiography shows air–fluid levels in patients with both viral and bacterial rhinosinusitis. Sinus computed tomography should not be used for routine evaluation of acute bacterial rhinosinusitis. However, sinus computed tomography without contrast media can be used to identify suspected complications and define anatomic abnormalities.

Differential Diagnosis

The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which can lead to overdiagnosis of acute bacterial rhinosinusitis. Other conditions that mimic bacterial rhinosinusitis are migraine headache, tension headache, trigeminal neuralgia, and temporomandibular joint disorders.

Treatment of Acute Rhinosinusitis

Symptomatic Treatment

Mild rhinosinusitis symptoms less than 7 days in duration can be managed with supportive care including analgesics, saline nasal irrigation, and intranasal corticosteroids. There are no randomized controlled trials that evaluate the effectiveness of decongestants in patients with sinusitis. Nasal saline is used to soften viscous secretions and improve mucociliary clearance. The mechanical cleansing of the nasal cavity with saline has been shown to benefit patients with rhinosinusitis. Most studies of intranasal corticosteroids are industry sponsored. A 2013 Cochrane review found that patients receiving intranasal corticosteroids were more likely to experience symptom improvement after 15 to 21 days compared with those receiving placebo (73% vs. 66.4%; p < .05; number needed to treat [NNT] = 15).

Antihistamines should not be used for symptomatic relief of acute rhinosinusitis except in patients with a history of allergic rhinitis.

Antibiotic Treatment

Antibiotic therapy is recommended for patients with sinusitis symptoms that do not improve within 7 to 10 days or that worsen at any time. Amoxicillin with or without clavulanate is recommended as the first-line antibiotic in adults with acute bacterial rhinosinusitis. “High dose” amoxicillin-clavulanate (Augmentin XR) is recommended for patients with high risk of S. pneumoniae resistance, recent antibiotic use, or treatment failure. Macrolides and trimethoprim sulfamethoxazole are not recommended for empiric therapy owing to high rates of resistance among S. pneumoniae and H. influenzae. Fluoroquinolones are not recommended as first-line antibiotics because they do not demonstrate benefit over beta-lactam antibiotics and are associated with a variety of adverse effects.

According to a recent FDA safety alert, fluoroquinolones should be reserved for patients who do not have other treatment options.

Complications and Referral

Complications of acute bacterial rhinosinusitis are estimated to occur in 1 in 1000 cases. Patients with acute bacterial rhinosinusitis who present with visual symptoms (diplopia, decreased visual acuity, disconjugate gaze, difficulty opening the eye), severe headache, somnolence, or high fever should be evaluated with emergent computed tomography with contrast. Sinonasal cancers are uncommon in the United States, with an annual incidence of less than 1 in 100,000 patients. However, cancer should be included in the differential diagnosis. Referral to an otolaryngologist is needed if symptoms persist or progress after maximal medical therapy when computed tomography shows evidence of sinus disease. Table 2 summarizes indications for subspecialist referral in a patient with acute bacterial rhinosinusitis.

Table 2

Indications for Subspecialist Referral for Acute Bacterial Rhinosinusitis

Anatomic defects causing obstruction

Complications such as orbital involvement, altered mental status, meningitis, cavernous sinus thrombosis, intracranial abscess, Pott’s puffy tumor (osteomyelitis of front bone)

Evaluation of immunotherapy for allergic rhinitis

Frequent recurrences (3–4 episodes per year)

Fungal sinusitis, granulomatous disease, or possible neoplasm

Immunocompromised host

Nosocomial infection

Severe infection with persistent fever > 102°F or 39°C

Treatment failure after extended antibiotic courses

Unusual or resistant bacteria

References

1.     Aring A.M., Chan M.M. Current concepts in adult acute rhinosinusitis. Am Fam Physician. 2016;94(2):97–105.

2.    Chow A.W., Benninger M.S., Brook I., et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–112 Epub 2012 Mar 20.

3.     Cornelius R.S., Martin J. Wippold, FJ 2nd, et al. ACR appropriateness criteria sinonasal disease. J Am Coll Radiol. 2013;10(4):241–246.

4.    DeSutter A.I., Lemiengre M., Campbell H. Antihistamines for the common cold. Cochrane Database Syst Rev. 2015;CD009345.

5.     Hayward G., Heneghan C., Perera R., Thompson M. Intranasal corticosteroids in management of acute sinusitis: A systematic review and meta-analysis. Ann Fam Med. 2012;10:241–249. doi:10.1370/afm.1338.

6.      King D., Mitchell B., Williams C.P., Spurling G.K.P. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database of Syst Rev. 2015;4:CD0006821doi:10.1002/14651858.CD006821.pub3.

7.    Lindbaek M., Hjortdahl P., Johnsen U. Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: Comparison with computer tomography. Fam Med. 1996;23:183–188.

8.    Rosenfeld R.M., Piccirillo J.F., Chadrasekhar S.S., et al. Clinical practice guideline (update): Adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2S):S1–39.

9.       U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. Available at http://www.fda.gov/Drugs/DrugSafety/ucm511530.htm [accessed January 28, 2017].

10.     Young J., De Sutter A., Merenstein D., et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: A meta-analysis of individual patient data. Lancet. 2008;371:908–914.

11.     Zalmanovici Trestioreanu A., Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;12:CD005149.

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