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Acute and Chronic Sinusitis

A Practical Guide for Diagnosis and Treatment

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Presentation Facts

• File size: approximately 2013 KB

• Number of slides: 81

• Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation

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Acknowledgments

This is a presentation of the American Academy of Family Physicianssupported by an educational grant from

Aventis Pharmaceuticals

The AAFP gratefully acknowledges Harold H. Hedges, III, M.D.

andSusan M. Pollart, M.D.

for developing the content for the AAFP

andHarold H. Hedges, III, M.D. for providing the

photo images included in this slide presentation.

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Acknowledgments

Harold H. Hedges, III, M.D.Private Practice

Little Rock Family Practice Clinic

Little Rock, Arkansas

and

Susan P. Pollart, M.D.Associate Professor of Family Medicine

University of Virginia Health SystemCharlottesville, Virginia

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Upon Completion of This Presentation You Should be Able To

• Be knowledgeable of the causes of and risk factors associated with sinusitis

• Differentiate acute from chronic sinusitis

• Evaluate patients by history, physical exam, appropriate laboratory and imaging studies, and when indicated screen patients for allergy

• Prescribe appropriate medication regimens for acute and chronic sinusitis

• Know of the relationships between upper airway (rhinosinusitis) and lower airway disease (asthma)

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Rhinosinusitis May be Better Term Because

• Allergic or nonallergic rhinitis nearly always precedes sinusitis

• Sinusitis without rhinitis is rare

• Nasal discharge and congestion are prominent symptoms of sinusitis

• Nasal mucosa and sinus mucosa are similar and are contiguous

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Scope of Sinusitis

• Affects 30-35 million persons/year

• 25 million office visits/year

• Direct annual cost $2.4 billion and increasing

• Added surgical costs: $1 billion

• Third most common diagnosis for which antibiotics are prescribed

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Normal Sinus

• Sinus health depends on:

– Mucous secretion of normal viscosity, volume, and composition,

– normal mucociliary flow to prevent mucous stasis and subsequent infection;

– and open sinus ostia to allow adequate drainage and aeration.

• Senior BA, Kennedy DW. Management of sinusitis in the asthmatic patient AAAI J,1996;77:6-19.

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Development of Sinuses

• Maxillary and ethmoid sinuses present at birth

• Frontal sinus developed by age 5 or 6

• Sphenoid sinus last to develop, 8-10

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Physiologic Importance of Sinuses

• Provide mucus to upper airways

– Lubrication

– Vehicle for trapping viruses, bacteria, foreign material for removal

• Give characteristics to voice

• Lessen skull weight

• Involved with olfaction

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Sinusitis

• 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells

– Frontal– Maxillary– Ethmoid– Sphenoid

Infectious or noninfectious inflammation of 1 or more sinuses

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Normal Water’s and Towne’ s Views of the Sinuses

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Lateral View Showing Normal Sphenoid Sinus

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Ostiomeatal Complex

• Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain

• Posterior ethmoids drain into the upper meatus

• Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

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Viral Rhinosinusitis

• Most upper respiratory infections are viral

• Short lived, last less than 10 days

• Sinus mucosa as well as nasal mucosa is involved

• Most will clear without antibiotics

• Treatment: decongestants, nasal lavage, rest, fluids

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Classification of Bacterial Sinusitis

• Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)

• Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days)

• Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)

• Some guidelines add treatment failure + a positive imaging study

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Recurrent Acute Bacterial Sinusitis

• Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic

• 3 episodes in 6 months or 4/year

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Acute Sinusitis Imposed on Chronic Sinusitis

• Patients with chronic, low grade symptoms experience increase in mucous flow, change in viscosity or color, or secretions

• Treated

• New symptoms resolve but chronic symptoms continue

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Differentiating Sinusitis from Rhinitis

Sinusitis

Nasal congestion

Purulent rhinorrhea

Postnasal drip

Headache

Facial pain

Anosmia

Cough, fever

Rhinitis

Nasal congestion

Rhinorrhea clear

Runny nose

Itching, red eyes

Nasal crease

Seasonal symptoms

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Road to Bacterial Sinus Infections

• Obstruction of the various ostia

• Impairment in ciliary function

• Increased viscosity of secretions

• Impaired immunity

• Mucus accumulates

• Decrease in oxygenation in the sinuses

• Bacterial overgrowth

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X-Ray Image of Sinuses with Maxillary Sinusitis

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Pathogenesis of Nasal Obstruction

• Viral upper respiratory infections

– Daycare centers

• Allergic and nonallergic stimuli

• Immunodeficiency disorders

– Immunoglobulin deficiency (IgA, IgG)

• Anatomic changes

– Deviated septum, concha bullosa, polyps

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Allergic Stimuli Causing Rhinosinusitis

• Pollens

– Tree, grass, weeds

• House dust mite

• Animal danders

– Cat, dog, mice, gerbil, other animals with fur

• Molds

• Allergic foods and beverages

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Nonallergic Stimuli Causing Rhinosinusitis

• Tobacco smoke

• Perfumes

• Cleaning solutions

• Potpourri

• Burning candles

• Cosmetics

• Car exhaust, diesel fumes

• Hair spray

• Cold air

• Dry air

• Changes in barometric pressure

• Auto exhaust

• Gas, diesel fuel

• Nonallergic foods

• Nonallergic beverages

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Causes of Ciliary Dysfunction

• Immotile cilia syndrome

• Prolonged exposure to cigarette smoke

• Common cold viruses causing URI

• Increased viscosity of mucus

• Medications– First generation antihistamines (non sedating do not affect)– Anticholinergics– Aspirin– Anesthetic agents– Benzodiazepines

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Diseases Slowing Ciliary Function

• Allergic and nonallergic rhinitis

• Rhinosinusitis

• Aging rhinitis

• Cystic fibrosis

• Any disease causing obstruction, crusting of the mucosa

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Causes of Mechanical Obstruction

• Deviated nasal septum

• Concha bullosa

• Foreign body

• Nasal polyps

• Congenital atresia

• Lymphoid hyperplasia

• Nasal structural changes found in Downs syndrome

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Vasculitides, Autoimmune and Granulomatous Diseases

• Churg-Strauss vasculitis

• Systemic lupus erythematosis

• Sjogren’s syndrome

• Sarcoidosis

• Wegener granulomatosis

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Other Predisposing Conditions

• Physical trauma

• Scuba diving

• Foreign body

• Cleft palate

• Dental disorders

• Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis

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Acute Bacterial Sinusitis

• Usually begins with viral upper respiratory illness

• Symptoms initially improve, but then …

• Symptoms become persistent or severe

• Persistent… 10-14 days but fewer than 4 weeks

• Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill

• Disease clears with appropriate medical treatment

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Physical Findings

• Mucopurulent nasal discharge

– Highest positive predictive value

• Swelling of nasal mucosa

• Mild erythema

• Facial pain (unusual in children)

• Periorbital swelling

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Objectives of Treatment of Acute Bacterial Sinusitis

• Decrease time of recovery

• Prevent chronic disease

• Decrease exacerbations of asthma or other secondary diseases

• Do so in a cost-effective way!

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Treatment of Acute Sinusitis

• Antihistamines recommended if allergy present– Oral or topical

• Decongestants– Oral or topical

• Antibiotic when indicated (bacteria)

• Nasal irrigation

• Guaifenesin 200-400 mg q4-6 hrs

• Hydration

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Decongestants

• Topical nasal sprays (limit use to 3-7 days)– Phenylephrine– Oxymetazoline– Naphthazoline– Tetrahydrozoline– Zylometazoline

• Topical nasal spray (unlimited daily use)– Ipatropium

• Oral – Pseudoephedrine 30-60 mg– Phenylephrine 2-4 times/day

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Treatment of Acute, Uncomplicated Sinusitis

• Antibiotic may not be indicated

– Many are viral

– Benefit of antibiotics are only moderate

– Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions

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Antibiotics for Acute Bacterial Sinusitis

• Amoxicillin 500 mg tid for 10-14 days

– First line choice in most areas

– Local differences in antibiotic resistance occur

• Where beta-lactanase resistance is an issue

– Amoxicillin/clavulanate

– Cefuroxime

– Cefpodoxime

– Cefprozil

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Additional Antibiotics for Acute Bacterial Sinusitis

• Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)

• If penicillin-allergic clarithromycin or azithromycin

• Erythromycin does not provide adequate coverage

• Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

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Nasal Irrigation

• Commercial buffered sprays

• Bulb syringe

– 1/4 tsp of salt to 7 ounces water

• Waterpik with lavage tip

– 1 tsp salt to reservoir

• Disposable enema bucket

– 2 tsp salt, 1 tsp soda per quart of water

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Nasal Irrigation

• Washes away irritants

• Moistens the dry nose

• Waterpik with nasal irrigator

• Ceramic irrigators

• Enema bucket with normal saline and soda

– “Hose-in-the-nose”-- $2.50

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Nasal Irrigation

• With enema bucket/hose….

– Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of warm water

– Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process.

– Use once, twice daily or as often as needed

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When Medical Therapy for Acute Bacterial Sinusitis Fails…

• Assess for chronic causes

– Identify allergic and nonallergic triggers

• Allergy testing, nasal smears for eosinophilia

– Consider other medical conditions associated with sinusitis

– Rhinolaryngoscopy

– Imaging studies

Sinus x-rays

CT scanning (limited, coronal views)

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Sinus Transillumination

• Helpful in older children and adults

• Normal transillumination decreases chance of pus in the sinus

• No light reflex suggests mucopurulent material or thickening of nasal mucosa

• Inexpensive screening tool

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Sinus Transillumination

• Have patient sit at your eye level in darkened room (the darker the better)

• Let eyes get accustomed to dark

• Place bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses

• Look at palate for presence/absence of transilluminated light

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Photo Image of Sinus Transilluminator

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Transillumination of Frontal Sinus

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Transillumination of Maxillary Sinus

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Rhinoscopy Aids in Diagnosing

• Nasal polyps

• Septal deviation

• Concha bullosa

• Eustachian tube dysfunction

• Causes of hoarseness

• Adenoid hyperplasia

• Tumors

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Rhinoscope

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CT Scan Maxillary and Ethmoid Sinuses

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MRI Imaging

• Not used for imaging suspected acute sinusitis

• Suspected fungal sinusitis

• Suspected tumors

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Bacteria Involved in Acute Bacterial Sinusitis

• Streptococcus pneumoniae 30%

• Haemophilus influenza 20%

• Moraxella catarrhalis 20%

• Sterile 30%

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Comparison of Various Approaches to the Treatment of AR

Sneezing Discharge Itch Congestion Side Effects

Antihistaminestraditional (A) +++ +++ +++ + +++

Non-sedating(NSA) +++ ++ +++ + – to +

Azelastine +++ ++ +++ + – to +

Decongestants – + – +++ ++

NSA + decongestants +++ +++ +++ +++ ++

Leukotriene antag.* + to ++ + to ++ + to ++ ++ – to +

Cromolyn ++ + + + –

Nasal CCS (NCS) +++ +++ +++ +++ +

NSA + NCS ++++ ++++ ++++ ++++ +

Immunotherapy +++ +++ +++ +++ + to ++

* Presumed; no data on individual symptoms. Nayak AS, et al. Ann Allergy Asthma Immunol. 2002;88:592-600. ++++ = Strongly positive effect; += Minimal effect

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Rational for Starting Rx with Amoxicillin

• In the absence of risk factors, i.e. attendance in daycare center, recent antibiotics, age younger than 2…

• 80% of patients will respond to amoxicillin

• Give Rx for 5 days with a refill -- if responding treat for 10 to 14 days, if not, switch to another

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Reasons to Use Alternative Antibiotics

• No response to amoxicillin within 3-5 days

• Recent treatment with amoxicillin for other causes

• Symptoms present for more than 30 days

• Recurrent sinus infections

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Secondary Antibiotics for Acute Sinusitis

• Cefdinir (Omnicef)

• Cefuroxime (Ceftin)

• Cephpodoxime (Vantin)

• Azithromycin

• Clarithromycin

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Optimal Duration of Antibiotics

Give antibiotic until patient free of symptoms then add 7 days

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Chronic Sinusitis

• Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children

• Eosinophilic inflammation or chronic infection

• Associated with positive CT scans

• Poor (if any) response to antibiotics

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Quality-of-Life Issues

• Fatigue

• Concentration

• Nuisance

• Sleep disturbance

• Emotional well being

• Social interactions

• Missing school/work

• Halitosis

• Decreased production

• Impaired studying

• Sniffing/snorting

• Blowing nose

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Sx of Chronic Sinusitis

• Nasal discharge

• Nasal congestion

• Headache

• Facial pain or pressure

• Olfactory disturbance

• Fever and halitosis

• Cough (worse when lying down)

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Conditions Causing Chronic Sinusitis

• Allergic and nonallergic rhinitis

• Uncorrected anatomic conditions

• Ciliary dyskinesia

• Cystic fibrosis

• Tumors

• Immunodeficiency disorders

– IgA, IgM

• Granulomatous diseases

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Evaluation of Chronic Sinusitis

• CT or MRI scanning

– Anatomic defects, tumors, fungi

• Allergy testing

– Inhalants, fungi, foods

• Sinus aspiration for cultures

– Bacterial

– Fungal

• Immunoglobulins

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Treatment of Chronic Sinusitis

• Nasal steroid spray

• Guafenesin

• Decongestants

• Steam inhalation

• Nasal irrigation

• Antibiotics with exacerbations

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Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown

• Streptococcus pneumoniae

• Haemophilus influenza

• Moraxella catarrhalis

• Staph aureus

• Coagulase negative staphylococcus

• Anerobic bacteria

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Transition of Bacteria Rom Acute to Chronic Sinusitis

• In one study, while initial aspirates showed strep pneumoniae, H. influenzae, and M catarrhalis, subsequent cultures showed Porphyromonas, Peptostreptococcus, and aerobic organisms found to be increasingly resistant to antibiotics– Brook I, et al. Bacteriology and beta-lactamase activity in

acute and chronic maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1996;122;418-23.

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Sinus Aspiration and Culture

• Correlation of routine nasal culture and sinus culture are poor

• Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture

– Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586.

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Recommendations Made for Antibiotic Prophylaxis in ABS

• Has not been evaluated as has its use in otitis media

• Increasing evidence of antibiotic resistance is an issue

• May be tried in chronic or recurrent disease

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Complications of Sinusitis

• Orbital

– Diplopia, proptosis

– Periorbital erythema, swelling

• Bone

– Periosteal abscesses

• Brain

– Intracranial abscesses causing neurologic symptoms

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The Sinusitis-Asthma Connection

• Mechanism is not understood

• Evidence is compelling

• Failure to control upper airway inflammation leads to suboptimal asthma control

• Correcting the rhinosinusitis results in better asthma control

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Indications for Referral

• Allergy testing, possible immunotherapy

• Sinus aspiration for bacterial culture

• Surgical intervention

– Correct obstructive process

– Drain sinus abscesses

– Consideration to remove nasal polyps

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Indications for Hospitalization

• Acutely ill child or adult with high fever, severe head pain

• Suspected sphenoid sinusitis

• Anytime complications of eye, bone or intracranial structures are present

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The Recommendations

The recommendations cited are those proposed by a task force of the American Academy of Pediatrics in consultation with other groups regarding the evaluation, diagnosis, and treatment of patients aged 1-21 years with sinus disease…expert opinion was used when insufficient data could be found.

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Recommendation 1

The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe.

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Recommendation 2a

• Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial)

• Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time

• Children < 6 symptoms predicted 88% of the time

• Normal x-ray suggests ABS is not present

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Recommendation 2b

• CT scans of the paranasal sinuses should be reserved for:

– Patients in whom surgery is being considered as a management strategy

– Patients who do not respond to medical regimes which include adequate antibiotic use

– Assisting in diagnosis of anatomical changes interfering with airflow or drainage

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Recommendations for CT Scans

• Patients presenting with complications of sinusitis

– Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema

• Patients with sinus symptoms accompanied by severe, boring, mid-head pain

– Rule out sphenoid sinusitis

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Recommendation 3

• Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure

• Patients must meet requirements of persistent or severe disease

• Response improved with doses >Minimal Inhibition Concentration

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No EB Recommendations Found for Use of Adjunctive Therapy in ABS, May be Helpful

• Nasal saline irrigation

• Oral decongestants

• Oral or nasal antihistamines

• Topical decongestants

• Mucolytic agents

• Topical steroids

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Summary

• Acute and chronic sinusitis is one of the most common diseases treated in family practice

• It is important to treat sinusitis aggressively to prevent chronic symptoms or development of serious complications

• The underlying causes of chronic sinus disease should be sought out and corrected

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Additional Bibliography

• Dykewicz M. Rhinitis and Sinusitis. J All Clin Immunol, 2003; 111:S520-9.

• Hamilos DL. J Allergy Clin Immunol 2000;106:213-27.

• Kaliner MA. Current Review of Rhinitis. Current Medicine, Inc., 2002.

• Kaliner MA. Current Review of Allergic Diseases. Current Medicine, Inc., 2000.

• Agency for Healthcare Research and Quality

• American Academy of Pediatrics

• New England Medical Center Evidence-based Practice Center

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Evidence-Based Recommendations

•Practice Recommendation: Reduce unnecessary use of antibiotics. Providers should be consistent with the recommended criteria for prescribing antibiotics in acute sinusitis endorsed by the CDC, American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America.

•Practice Recommendation: Use first line antibiotics, which are amoxicillin or trimethoprim-sulphamethoxazole (TMP/SMX).

•Practice Recommendation: Use an antibiotic that covers resistant bacteria (amoxicillin-clavulanate [Augmentin] or another second line agent) to treat patients if failed on 10-14 days of amoxicillin.

All recommendations available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=148.

Accesses August 2003.

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Thank You

This has been a presentation of the American Academy of Family Physicians