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Sinusitis (Rhinosinusitis), Emergency Medicine

Basics

Description

- Acute rhinosinusitis pathophysiology: - Viral upper respiratory infection or allergies causes mucous membrane inflammation - Inflammation causes obstruction of sinus ostia, decreased mucociliary clearance, and thickening of secretions - Viruses are the primary cause, but 0.5 " “2.2% develop into bacterial infection after bacteria become trapped and multiply, resulting in suppuration - Nosocomial rhinosinusitis associated with nasogastric and nasotracheal tubes - Immunocompromised patients at higher risk for rhinosinusitis

- Subacute and chronic rhinosinusitis pathophysiology: - Multifactorial, role of bacteria remains elusive - Allergic inflammation causing narrowed ostia and blocked drainage - Immune dysfunction leading to increased infectious risk - Impaired ciliary function leading to decreased mucous clearance - Odontogenic infection causing maxillary sinusitis - Fungus ball - Anatomical obstruction or polyps obstructing sinus ostia

- Nosocomial rhinosinusitis: - S. aureus - Streptococcal species - Pseudomonas - Klebsiella

- CT: - Preferred if imaging is necessary - Warranted in patients with complicated rhinosinusitis, severe headache, seizures, focal neurologic deficits, periorbital edema, or abnormal intraocular muscle function - IV contrast if concern for osteomyelitis or abscess

- Uncomplicated viral or allergic rhinitis - Otitis media - Dacryocystitis - Migraine and cluster headache - Dental pain - Trigeminal neuralgia - Temporomandibular joint disorders - Giant cell arteritis/temporal arteritis - Rhinitis medicamentosa (decongestants, Ž ˛-blockers, antihypertensives, birth control pills) - Nasal polyp, tumor, or foreign body - CNS infection - Granulomatous or ciliary disease - Aspergillosis - Rhinocerebral mucormycosis: - Rare rapidly progressive fungal infection - Occurs in diabetics and the immunocompromised - Orbital/facial pain out of proportion to exam - Lethargy, headache in a systemically ill-appearing patient - Black eschar or pale area on the palate or nasal mucosa

- Rhinitis of pregnancy: - Estrogen has cholinergic effect on mucosa - Worse during 3rd trimester - Resolves within 2 wk postpartum

- Nonantibiotic therapies: - Pain control - Saline nasal irrigation may be beneficial - Oral corticosteroids as adjunctive to oral antibiotics are effective, but data limited - Intranasal steroids recommended as adjunct to antibiotics primarily in those with allergies: - Beclomethasone dipropionate: 1 spray per nostril QD/TID/BID - Dexamethasone sodium phosphate: 2 sprays per nostril BID/TID

  • Inflammation of mucous membranes lining the paranasal sinuses and nasal passages with or without fluid collection in the sinus cavities
  • Classifications:Acute: Signs and symptoms for <4 wkSubacute: Signs and symptoms for 4 " “8 wkChronic: Signs and symptoms for >8 wk in spite of antibiotic treatmentRecurrent: 3 or more episodes per year

Etiology

  • Acute rhinosinusitis pathophysiology:Viral upper respiratory infection or allergies causes mucous membrane inflammationInflammation causes obstruction of sinus ostia, decreased mucociliary clearance, and thickening of secretionsViruses are the primary cause, but 0.5 " “2.2% develop into bacterial infection after bacteria become trapped and multiply, resulting in suppurationNosocomial rhinosinusitis associated with nasogastric and nasotracheal tubesImmunocompromised patients at higher risk for rhinosinusitis
  • Subacute and chronic rhinosinusitis pathophysiology:Multifactorial, role of bacteria remains elusiveAllergic inflammation causing narrowed ostia and blocked drainageImmune dysfunction leading to increased infectious riskImpaired ciliary function leading to decreased mucous clearanceOdontogenic infection causing maxillary sinusitisFungus ballAnatomical obstruction or polyps obstructing sinus ostia
  • Microbiology:Acute rhinosinusitis:Nontypable Haemophilus influenzaeStreptococcus pneumoniaeMoraxella catarrhalisStaphylococcus aureusAnaerobesViruses: Parainfluenza, adenovirus, rhinovirus, influenzaChronic rhinosinusitis:Same as acute, often polymicrobial, with increasing anaerobes and gram negativesNosocomial rhinosinusitis:S. aureusStreptococcal speciesPseudomonasKlebsiellaImmunocompromised patients with rhinosinusitis:Bacteria as aboveFungal pathogens (Aspergillus)
  • Nontypable H. influenzae more common than S. pneumoniae as cause of acute bacterial rhinosinusitis in children
  • Ethmoid and maxillary sinuses present at birth
  • Frontal and sphenoid sinuses do not emerge until age 6 " “7 yr
  • Rhinosinusitis more common in children
  • Periorbital/orbital cellulitis is a common complication of ethmoid rhinosinusitis in children:Periorbital swelling, fever, ptosis, proptosis, and painful or decreased extraocular movements

Diagnosis

Signs and Symptoms

  • Facial " “dental pain, headache, halitosis, hyposmia, cough
  • Purulent nasal discharge and postnasal drainage
  • Fever
  • Frontal sinusitis:Pain of the lower foreheadPain worsened when lying on the back; improves when upright
  • Maxillary sinusitis:Malar facial painMaxillary dental painReferred ear painPain worsens with head upright or bending forward and improves with reclining
  • Ethmoid sinusitis:Retro-orbital painPeriorbital edema
  • Sphenoid sinusitis (very uncommon):Pain over the occiput or mastoidPain worse when lying on back or bending forward

History

  • Acute viral rhinosinusitis:Symptoms typically resolve in 7 " “10 days
  • Acute bacterial rhinosinusitis needing antibiotic treatment can present in 3 different patterns:Pattern 1: Persistent symptoms lasting >10 days without improvementPattern 2: Severe symptoms or:Temperature ≥39 ‚ °C and purulent nasal discharge for 3 " “4 days at the beginning of illnessPattern 3: Worsening symptoms:Return of symptoms after a 5 " “6- day duration of upper respiratory infection that was improving
  • Other important history:Symptom history and time courseAllergy historyRecent NG or NT tube placementImmunocompromised state

Physical Exam

  • Vital signs, toxic/nontoxic appearance
  • Edema of the nasal mucous membranes and turbinates
  • Purulence in the nares or posterior pharynx
  • Warmth, tenderness, or cellulitis over sinus
  • Sinus tenderness on palpation
  • Periorbital edema
  • Failure of transillumination of maxillary sinuses:Observed through the palate
  • Dental exam revealing abscess or tenderness of maxillary teeth

Essential Workup

  • Clinical diagnosis based on history and physical exam
  • Determine if patient fits pattern of acute bacterial rhinosinusitis that should be treated with antibiotics (see "History " ť)

Diagnosis Tests & Interpretation

Lab

Lab studies not helpful for diagnosis or management ‚

Imaging

  • Imaging unnecessary in uncomplicated cases
  • Plain-film radiography:Normal films do not exclude bacterial causeWaters view can be ordered, but has moderate sensitivity in diagnosing maxillary sinus abnormality and poor sensitivity in diagnosing lesions in other sinusesOdontogenic maxillary sinusitis may be missed by dental exam and panorex films, but is apparent as periapical lucency on cone beam CT or sinus CT
  • CT:Preferred if imaging is necessaryWarranted in patients with complicated rhinosinusitis, severe headache, seizures, focal neurologic deficits, periorbital edema, or abnormal intraocular muscle functionIV contrast if concern for osteomyelitis or abscess

Diagnostic Procedures/Surgery

  • Sinus aspirate culture:Gold standard for making a microbial diagnosis but not routinely performed
  • Culture of discharge may have benefit but remains unstudied and is not typically performed
  • Functional endoscopic sinus surgery (FESS):Restores physiologic sinus drainage

FESS is a safe and effective treatment in children ‚

Differential Diagnosis

  • Uncomplicated viral or allergic rhinitis
  • Otitis media
  • Dacryocystitis
  • Migraine and cluster headache
  • Dental pain
  • Trigeminal neuralgia
  • Temporomandibular joint disorders
  • Giant cell arteritis/temporal arteritis
  • Rhinitis medicamentosa (decongestants, Ž ˛-blockers, antihypertensives, birth control pills)
  • Nasal polyp, tumor, or foreign body
  • CNS infection
  • Granulomatous or ciliary disease
  • Aspergillosis
  • Rhinocerebral mucormycosis:Rare rapidly progressive fungal infectionOccurs in diabetics and the immunocompromisedOrbital/facial pain out of proportion to examLethargy, headache in a systemically ill-appearing patientBlack eschar or pale area on the palate or nasal mucosa
  • Rhinitis of pregnancy:Estrogen has cholinergic effect on mucosaWorse during 3rd trimesterResolves within 2 wk postpartum

Treatment

Pre-Hospital

No special considerations ‚

Initial Stabilization/Therapy

Toxic-appearing patients may require airway management and fluid resuscitation. ‚

Ed Treatment/Procedures

  • Identifying rhinosinusitis needing antibiotics
  • Counseling and reassurance to patients requesting antibiotics for mild symptoms <10 days duration

Medication

  • Nonantibiotic therapies:Pain controlSaline nasal irrigation may be beneficialOral corticosteroids as adjunctive to oral antibiotics are effective, but data limitedIntranasal steroids recommended as adjunct to antibiotics primarily in those with allergies:Beclomethasone dipropionate: 1 spray per nostril QD/TID/BIDDexamethasone sodium phosphate: 2 sprays per nostril BID/TIDAntihistamines recommended for patients with underlying allergyNasal or oral decongestants not recommended (phenylephrine, pseudoephedrine, oxymetazoline)Expectorants may be helpful:Guaifenesin:Adult: 200 " “400 mg PO; not >2.4 g/24 hPeds 2 " “5 yr: 50 " “100 mg PO; not >600 mg/24 h;Peds 6 " “11 yr: 100 " “200 mg PO; not >1.2 g/24 h
  • Antibiotics:Amoxicillin " “clavulanate: 250 " “500 mg PO TID or 875 mg PO BID (peds: 40 mg/kg/d, based on the amoxicillin component)If high risk (systemic toxicity w/fever ≥39 ‚ °C, attendance at daycare, age <2 or >65 yr, recent hospitalization, abx use in last month, or immunocompromised) use amoxicillin " “clavulanate: 2 g PO BID (peds: 90 mg/kg/d, based on amoxicillin component)Doxycycline: 100 mg PO BID (alternative for initial empiric therapy in adults)
  • 2nd- and 3rd-generation oral cephalosporins no longer recommended for empiric monotherapy due to resistance among S. pneumoniae. Can use following combination:Cefpodoxime: 200 " “400 mg PO BID (peds: 10 mg/kg/d PO BID) orCefuroxime: 250 " “500 mg PO BID (peds: 15 mg/kg/d PO BID) +Clindamycin: 150 " “300 mg PO q6h (peds: 8 " “16 mg/kg/d PO split q6 " “8h, MRSA-suspected use 40 mg/kg/d PO split q6 " “8h)
  • Macrolides (clarithromycin and azithromycin) not recommended due to high rates of resistance amongst S. pneumoniae (30%)
  • Trimethoprim " “sulfamethoxazole (TMP/SMX) not recommended due to high rates of resistance among S. pneumoniae and H. influenzae (30 " “40%)
  • Type 1 penicillin allergy:Levofloxacin: 500 mg PO per day (peds: 8 mg/kg) children under 50 kg max. dose 250 mg/d. Children over 50 kg max. dose 500 mg/d.Moxifloxacin: 400 mg PO per day (adult)
  • If symptoms not improved after 3 " “5 days of 1 antibiotic, switch to another antibiotic
  • Recommended duration of therapy:Acute: 10 " “14 days in children; 5 " “7 days in adultsChronic: 3 " “6-wk course of antibiotics (controversial), douche, and nasal steroids

First Line

Supportive care ‚

Second Line

Antibiotics ‚

Follow-Up

Disposition

Admission Criteria

  • Evidence of spread of infection beyond the sinus cavity or toxic-appearing patients
  • Immunocompromised/diabetic patients with extensive infection
  • Multiple sinus or frontal sinus involvement
  • Extremes of age
  • Severe comorbidity
  • ENT evaluation and aspiration if patient is severely ill, immunocompromised, or has pansinusitis and is ill-appearing

Discharge Criteria

Most cases of uncomplicated rhinosinusitis may be managed on an outpatient basis. ‚

Issues for Referral

  • Complications of acute infection
  • Immunocompromised patients
  • Chronic rhinosinusitis or nasal polyps
  • Concerns for osteomyelitis, CNS infection, or abscess
  • Acute rhinosinusitis " “aspergillosis

Followup Recommendations

If patient has no relief with initial treatment and nonantibiotic therapies, follow up with PCP or ENT. ‚

Pearls and Pitfalls

  • Patients presenting with <10 days of mild symptoms should be treated with supportive care
  • Patients presenting with ≥10 days of symptoms, severe symptoms at 4 " “5 days with fever, or worsening after initial improvement can be diagnosed with acute bacterial rhinosinusitis and should be treated with antibiotics
  • Term rhinosinusitis preferred, since inflammation of sinuses rarely occurs without inflammation of the nasal mucosa

Additional Reading

  • Ahovuo-Saloranta ‚ A, Borisenko ‚ OV, Kovanen ‚ N, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008;(2):CD000243.
  • Aring ‚ AM, Chan ‚ MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83:1057 " “1063.
  • Chow ‚ AW, Benninger ‚ MS, Brook ‚ I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e72 " “e112.
  • DeMuri ‚ GP, Wald ‚ ER. Clinical practice. Acute bacterial sinusitis in children. N Engl J Med. 2012;367:1128 " “1134.
  • Lemiengre ‚ MB, van Driel ‚ ML, Merenstein ‚ D, et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;10:CD006089.
  • Shaikh ‚ N, Wald ‚ ER, Pi ‚ M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909.
  • Venekamp ‚ RP, Thompson ‚ MJ, Hayward ‚ G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst. Rev. 2011;(12):CD008115.

Codes

ICD9

  • 461.9 Acute sinusitis, unspecified
  • 473.0 Chronic maxillary sinusitis
  • 473.9 Unspecified sinusitis (chronic)
  • 473.2 Chronic ethmoidal sinusitis
  • 473.1 Chronic frontal sinusitis
  • 473.8 Other chronic sinusitis
  • 473 Chronic sinusitis
  • 477.9 Allergic rhinitis, cause unspecified

ICD10

  • J01.90 Acute sinusitis, unspecified
  • J32.0 Chronic maxillary sinusitis
  • J32.9 Chronic sinusitis, unspecified
  • J32.2 Chronic ethmoidal sinusitis
  • J30.9 Allergic rhinitis, unspecified
  • J32.1 Chronic frontal sinusitis
  • J32.4 Chronic pansinusitis
  • J32.8 Other chronic sinusitis
  • J32 Chronic sinusitis

SNOMED

  • 15805002 Acute sinusitis (disorder)
  • 40055000 Chronic sinusitis (disorder)
  • 88348008 Maxillary sinusitis (disorder)
  • 18643000 Ethmoidal sinusitis
  • 195790000 pansinusitis (disorder)
  • 36971009 Sinusitis (disorder)
  • 78737005 Frontal sinusitis