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Sinusitis
Chirag N. Shah, MD
Patrick J. Rogers, DO
image BASICS
DESCRIPTION
  • Acute sinusitis is a symptomatic inflammation of ≥1 paranasal sinuses of <4 weeks' duration resulting from impaired drainage and retained secretions accompanied by obstruction, facial pain/pressure/fullness, or both. Because rhinitis and sinusitis usually coexist, “rhinosinusitis” is the preferred term.
  • Disease is subacute when symptomatic for 4 to 12 weeks, recurrent acute when ≥4 annual episodes without persistent symptoms in between and chronic when symptomatic for >12 weeks.
  • Uncomplicated rhinosinusitis has no extension of inflammation beyond paranasal sinuses and nasal cavity.
  • System(s) affected: head/eyes/ears/nose/throat (HEENT), pulmonary
EPIDEMIOLOGY
  • Affects one in eight adults accounting for >30 million individuals in the United States each year diagnosed with rhinosinusitis
  • Diagnosis of acute bacterial rhinosinusitis remains the fifth leading reason for prescribing antibiotics.
  • 0.5-2% of viral rhinosinusitis episodes have a bacterial superinfection.
  • Viral cause in 90-98% of cases
Incidence
Incidence is highest in early fall through early spring (related to incidence of viral upper respiratory infection [URI]). Adults have two to three viral URIs per year; 90% of these colds are accompanied by viral rhinosinusitis. It is the fifth most common diagnosis made during family physician visits.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Important features
    • Inflammation and edema of the sinus mucosa
    • Obstruction of the sinus ostia
    • Impaired mucociliary clearance
  • Secretions that are not cleared become hospitable to bacterial growth.
  • Inflammatory response (neutrophil influx and release of cytokines) damages mucosal surfaces.
  • Viral: vast majority of cases (rhinovirus; influenza A and B; parainfluenza virus; respiratory syncytial; adeno-, corona-, and enteroviruses)
  • Bacterial (complicates 0.5-2% of viral cases)
    • More likely if symptoms worsen within 5 to 6 days after initial improvement
    • No improvement within 10 days of symptom onset
    • >3 to 4 days of fever >102°F and facial pain and purulent nasal discharge
    • Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial pathogens.
    • Often overdiagnosed, which leads to overuse of and increasing resistance to antibiotics
    • Methicillin-resistant Staphylococcus aureus present in 0-15.9% of patients.
  • Fungal: seen in immunocompromised hosts (uncontrolled diabetes, neutropenia, use of corticosteroids) or as a nosocomial infection
Genetics
No known genetic pattern
RISK FACTORS
  • Viral URI
  • Allergic rhinitis
  • Asthma
  • Cigarette smoking
  • Dental infections and procedures
  • Anatomic variations
    • Tonsillar and adenoid hypertrophy
    • Turbinate hypertrophy, nasal polyps
    • Cleft palate
  • Immunodeficiency (e.g., HIV)
  • Cystic fibrosis (CF)
GENERAL PREVENTION
  • Hand washing to prevent transmission of viral infection
  • Childhood vaccinations up to date
  • Avoid close contacts with symptomatic individuals.
  • Avoid smoking and exposure to second hand smoke.
image DIAGNOSIS
  • History and physical exam suggest and establish the diagnosis but are rarely helpful in distinguishing bacterial from viral causes.
  • Use a constellation of symptoms rather than a particular sign or symptom in diagnosis.
PHYSICAL EXAM
  • Fever
  • Edema and erythema of nasal mucosa
  • Purulent discharge
  • Tenderness to palpation over sinus(es)
  • Pain localized to sinuses when bending forward
  • Transillumination of the sinuses may confirm fluid in sinuses (helpful if asymmetric; not helpful if symmetric exam).
Pediatric Considerations
  • Sinuses are not fully developed until age 20 years. Maxillary and ethmoid sinuses, although small, are present from birth.
  • Because children have an average of six to eight colds per year, they are at risk for developing sinusitis.
  • Diagnosis can be more difficult than in adults because symptoms are often more subtle.
DIFFERENTIAL DIAGNOSIS
  • Dental disease
  • CF
  • Wegener granulomatosis
  • HIV infection
  • Kartagener syndrome
  • Neoplasm
  • Headache, tension, or migraine
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic tests are not routinely recommended; no diagnostic tests can adequately differentiate between viral and bacterial rhinosinusitis (2)[C].
  • None indicated in routine evaluation
  • Routine use of sinus radiography discouraged because of the following:
    • ≥3 clinical findings have similar diagnostic accuracy as imaging.
    • Imaging does not distinguish viral from bacterial etiology.
  • Limited coronal CT scan can be useful in recurrent infection or failure to respond to medical therapy.
Diagnostic Procedures/Other
Sinus CT if signs suggest extrasinus involvement or to evaluate chronic rhinosinusitis
Test Interpretation
  • Inflammation, edema, thickened mucosa
  • Impaired ciliary function
  • Metaplasia of ciliated columnar cells
  • Relative acidosis and hypoxia within sinuses
  • Polyps
image TREATMENT
Most cases resolve with supportive care (treating pain, nasal symptoms). Antibiotics should be reserved for symptoms that persist >10 days, onset with severe symptoms (high fever, purulent nasal discharge, facial pain) for at least 3 to 4 consecutive days, or worsening signs/symptoms that were initially improving (1,2)[C].
GENERAL MEASURES
  • Hydration
  • Steam inhalation 20 to 30 minutes TID
  • Saline irrigation (Neti pot) or nose drops
  • Sleep with head of bed elevated.
  • Avoid exposure to cigarette smoke or fumes.
  • Avoid caffeine and alcohol.
  • Antibiotics are indicated only when findings suggest bacterial infection.
  • Analgesics, NSAIDs
  • Acute viral sinusitis is self-limiting; antibiotics should not be used.
MEDICATION
First Line
  • Decongestants
    • Pseudoephedrine HCl
    • Phenylephrine nasal spray (limited use)
    • Oxymetazoline nasal spray (e.g., Afrin) (not to be used >3 days)
  • Analgesics
    • Acetaminophen
    • Aspirin
    • NSAIDs
  • P.969

  • Antibiotics
    • Antibiotics have a slight advantage over placebo at 7 to 14 days (3)[A], yet most improve without therapy.
    • Reserve antibiotic use for patients with moderate to severe disease.
    • Choice should be based on understanding of antibiotic resistance in the community.
    • Infectious Disease Society of America recommends the following (1)[C]:
      • Start antibiotics as soon as clinical diagnosis of acute bacterial sinusitis is made.
      • Use amoxicillin-clavulanate rather than amoxicillin alone.
      • Amoxicillin-clavulanate 875/125 mg q12h; 2 g orally BID in geographic regions with high rates of resistant S. pneumoniae
      • Doxycycline: 100 mg PO BID an alternative to amoxicillin-clavulanate for initial therapy (adults only)
      • Trimethoprim-sulfamethoxazole (TMP/SMX) and 3rd generation cephalosporins not recommended due to high rate of resistance (1)[C]
      • Treat for 5 to 7 days in adults if uncomplicated bacterial rhinosinusitis (IDSA low-moderatequality evidence). Treat for 10 to 14 days in children if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence).
    • American Academy of Pediatrics recommends the following (1)[C]:
      • Amoxicillin: 45 to 90 mg/kg/day in 2 divided doses if uncomplicated acute bacterial sinusitis in children
      • Amoxicillin-clavulanate: 80 to 90 mg/6.4 mg/kg/day in 2 divided doses for children with severe illness, recent antibiotics, or attending daycare
      • Levofloxacin: 10 to 20 mg/kg/day max 750mg/day if history of type 1 hypersensitivity to PCN (1)[C]
      • Clindamycin (30 to 40 mg/kg/day) + cefixime (8mg/kg/day in 2 divided doses) or cefpodoxime (10 mg/kg/day in 2 divided doses) (1)[C] for non-type 1 PCN allergy
      • Ceftriaxone: 50 mg/kg IM single dose if not able to tolerate oral meds (4)[C]
  • Because allergies may be a predisposing factor, some patients may benefit from use of the following agents:
    • Oral antihistamines
      • Loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), desloratadine (Clarinex), or levocetirizine (Xyzal)
      • Chlorpheniramine (Chlor-Trimeton)
      • Diphenhydramine (Benadryl)
    • Leukotriene inhibitors (Singulair, Accolate), especially in patients with asthma
    • Nasal steroids (i.e., fluticasone [Flonase])
Second Line
  • Levofloxacin (Levaquin): 750 mg/day for 5 days or moxifloxacin 400 mg/day for 5 to 7 days (adults only) (1)[C]
  • If no response to first-line therapy after 72 hours
    • Broaden antibiotic coverage or switch to a different class, evaluate for resistant pathogens or other causes for treatment failure (i.e., noninfectious etiology) fluoroquinolones as above.
  • Note: Bacteriologic failure rates of up to 20-25% are possible with use of azithromycin and clarithromycin.
  • If lack of response to 3 weeks of antibiotics, consider the following:
    • CT scan of sinuses
    • Ear/nose/throat (ENT) referral
ISSUES FOR REFERRAL
Complications or failure of treatment
Pregnancy Considerations
  • Nasal irrigation with saline, pseudoephedrine, most antihistamines, and some nasal steroids are safe during pregnancy and lactation.
  • Antibiotics safe in pregnancy and lactation
    • Amoxicillin, amoxicillin-clavulanate, cephalosporins
  • Antibiotic contraindicated: doxycycline, fluoroquinolones
  • Antibiotic safe in lactation but not pregnancy: levofloxacin
SURGERY/OTHER PROCEDURES
  • If medical therapy fails, consider sinus irrigation.
  • Functional endoscopic sinus surgery is the preferred treatment for medically recalcitrant cases.
  • Absolute surgical indications
    • Massive nasal polyposis
    • Acute complications: subperiosteal or orbital abscess, frontal soft tissue spread of infection
    • Mucocele or mucopyocele
    • Invasive or allergic fungal sinusitis
    • Suspected obstructing tumor
    • CSF rhinorrhea
INPATIENT CONSIDERATIONS
Hospitalization for complications (e.g., meningitis, orbital cellulitis or abscess, brain abscess)
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Return if no improvement after 72 hours or no resolution of symptoms after 10 days of antibiotics.
PATIENT EDUCATION
  • http://familydoctor.org/familydoctor/en.html
  • https://www.nlm.nih.gov/medlineplus/
PROGNOSIS
Alleviation of symptoms within 72 hours with complete resolution within 10 to 14 days
REFERENCES
1. 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(8):e72-e112.
2. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl): S1-S39.
3. Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;(2):CD000243.
4. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
5. Olarte L, Hulten KG, Lamberth L, et al. Impact of the 13-valent pneumococcal conjugate vaccine on chronic sinusitis associated with Streptococcus pneumoniae in children. Pediatr Infect Dis J. 2014; 33(10):1033-1036.
6. Hayward G, Heneghan C, Perera R, et al. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012;10(3):241-249.
Additional Reading
&NA;
  • Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057-1063.
  • Centers for Disease Control and Prevention. Get Smart: homepage. http://www.cdc.gov/getsmart/.
  • Williams JW Jr, Aguilar C, Cornell J, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2003;(2):CD000243.
  • Wilson JF. In the clinic. Acute sinusitis. Annal Intern Med. 2010;153(5):ITC3-1-ITC3-15.
Codes
&NA;
ICD10
  • J01.90 Acute sinusitis, unspecified
  • J01.00 Acute maxillary sinusitis, unspecified
  • J01.20 Acute ethmoidal sinusitis, unspecified
Clinical Pearls
&NA;
  • When bacterial infection is present, patients recover somewhat more quickly with antibiotics, but the majority will recover with symptomatic treatment alone, and accurate diagnosis of bacterial sinusitis is very difficult.
  • Multiple meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.
  • Overall NNT to prevent 1 persistent case at follow-up = 15; harm due to antibiotic-associated diarrhea is similar.
  • Significant patient symptom relief with nasal saline spray or drops or irrigation (Neti pot)