Basics
Description
- 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 wk
- Subacute: Signs and symptoms for 4 " “8 wk
- Chronic: Signs and symptoms for >8 wk in spite of antibiotic treatment
- Recurrent: 3 or more episodes per year
Etiology
- 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
- Microbiology:
- Acute rhinosinusitis:
- Nontypable Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
- Staphylococcus aureus
- Anaerobes
- Viruses: Parainfluenza, adenovirus, rhinovirus, influenza
- Chronic rhinosinusitis:
- Same as acute, often polymicrobial, with increasing anaerobes and gram negatives
- Nosocomial rhinosinusitis:
- S. aureus
- Streptococcal species
- Pseudomonas
- Klebsiella
- Immunocompromised patients with rhinosinusitis:
- Bacteria as above
- Fungal 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 forehead
- Pain worsened when lying on the back; improves when upright
- Maxillary sinusitis:
- Malar facial pain
- Maxillary dental pain
- Referred ear pain
- Pain worsens with head upright or bending forward and improves with reclining
- Ethmoid sinusitis:
- Retro-orbital pain
- Periorbital edema
- Sphenoid sinusitis (very uncommon):
- Pain over the occiput or mastoid
- Pain 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 improvement
- Pattern 2: Severe symptoms or:
- Temperature ≥39 ‚ °C and purulent nasal discharge for 3 " “4 days at the beginning of illness
- Pattern 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 course
- Allergy history
- Recent NG or NT tube placement
- Immunocompromised 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 cause
- Waters view can be ordered, but has moderate sensitivity in diagnosing maxillary sinus abnormality and poor sensitivity in diagnosing lesions in other sinuses
- Odontogenic 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 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
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 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
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 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
- Antihistamines recommended for patients with underlying allergy
- Nasal or oral decongestants not recommended (phenylephrine, pseudoephedrine, oxymetazoline)
- Expectorants may be helpful:
- Guaifenesin:
- Adult: 200 " “400 mg PO; not >2.4 g/24 h
- Peds 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) or
- Cefuroxime: 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 adults
- Chronic: 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