SINUSITIS(RHINOSINUSITIS)

Fran Connolly FNP-S

Sinusitis is a symptomatic inflammation of the paranasal sinuses resulting from impaired drainage and retained secretions (Domino, 2014).

Conditions that obstruct the openings that drain the sinuses (Porth, 2011). Because rhinitis and sinusitis usually coexist, “rhinosinusitis” is the preferred

term (Domino, 2014). The mucosa of the nasal cavities & paranasal sinuses are lined with a

continuous mucus membrane layer & sinusitis rarely occurs in the absence of infectious or allergic rhinitis (Porth, 2011).

Acute is an abrupt onset which lasts less than 4 weeks, subacute when symptomatic for 4-12 weeks and chronic when > 12 weeks (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Sinusitis

The paranasal sinuses are air-filled areas of the nasal cavities into the frontal, ethmoid, sphenoid, and maxilla bones.

Sinuses are connected by narrow openings called ostia with the superior, middle and inferior nasal turbinates of the nasal cavity.

The anterior ethmoid, frontal and maxillary sinuses drain to the nasal cavity through the osteomeatal complex.

The sphenoidal sinuses drain from a complex between the septum and the superior turbinate.

(Porth, 2011)

Sinuses

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

(Domino, 2014)

Pathophysiology

Viral: vast majority of cases (rhinovirus, influenza A & B, parainfluenza virus, and enteroviruses) (Domino, 2014). Viral infections usually last 5-7 days (Porth, 2011).

Bacterial: More likely if symptoms worsen after 5-7 days or do not improve after 10 days (Domino,

2014). S. pneumonia, H. influenza, & M. catarrhalis are the most common in acute (Porth, 2011). S. aureus, staphylococcus & anaerobic gram negative bacilli are most common in chronic

(Porth, 2011). Often over diagnosed, which leads to overuse and increasing resistance to antibiotics

(Domino, 2014). Acute bacterial infections can last up to 4 weeks (Porth, 2011).

Fungal: seen in immunocompromised hosts or as a nosocomial infection (Domino, 2014).

Etiology

Affects 31 million people in the US each year, with an estimated annual cost of $5.8 billion (Domino, 2014).

Acute bacterial sinusitis accounts for 16 million clinical visits each year (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Diagnosis of the acute bacterial rhinosinusitis remains the 5th leading cause for prescribing antibiotics (Domino, 2014).

2% of viral rhinosinusitis episodes have a bacterial superinfection (Domino, 2014).

An estimated 0.5% of all colds are complicated by bacterial infection of the sinuses (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Epidemiology

Highest in early fall through early spring (r/t incidence of viral upper respiratory infections) (Domino, 2014).

Adults have 2-3 viral URI’s per year, 90% are accompanied by viral rhinosinusitis (Domino, 2014).

More than 95% of acute sinusitis are caused by the same viruses associated with uncomplicated URIs (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Incidence

Viral URI Allergic rhinitis Asthma Smoking Dental infections Anatomic variations

Tonsillar and adenoid hypertrophy Turbinate hypertrophy, nasal polyps Deviated septum Cleft palate

Immunodeficiency Cystic fibrosis (Domino, 2014)

Risk Factors

H&P exam suggest and establish the diagnosis, but are rarely helpful in distinguishing bacterial from viral causes (Domino, 2014).

Use a constellation of symptoms rather than a particular sign or symptom in diagnosis (Domino, 2014).

Diagnosis

Symptoms somewhat predictive of bacterial sinusitis: Worsening of symptoms greater than 5-7 days after initial improvement Persistent symptoms for 10 days or greater Persistent purulent nasal discharge Unilateral upper tooth or facial pain Unilateral maxillary sinus tenderness Pain on bending Fever

(Domino, 2014)

Clinical Findings

Associated symptoms: Headache Nasal congestion Retro-orbital pain Otalgia Hyposomia Halitosis Chronic cough

Symptoms requiring urgent attention: Visual disturbances, especially diplopia Periorbital swelling or erythema Altered mental status (Domino, 2014)

Clinical Findings (continued)

Fever Edema or erythema of nasal mucosa, turbinates (Domino, 2014) Purulent drainage Tenderness to palpation over sinuses Transillumination of the sinuses may confirm fluid in sinuses (only

helpful if asymmetric) (Porth, 2011) Percussion of sinuses can cause pain or tenderness in teeth or gums,

which can be related to dental abscesses (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Physical Exam

Sinuses are not fully developed until 20 years old. Maxillary and ethmoid sinuses are present from birth (Domino, 2014).

Sinuses reach their permanent size, but not shape by age 12 (Burns, et al, 2013).

Since children have an average of 6-8 colds per year, they are at risk for developing sinusitis (Domino, 2014).

Diagnosis can be more difficult because symptoms can be more subtle (Domino, 2014).

Pediatric Consideration

Dental disease Cystic fibrosis Wegener granulomatosis HIV infection Kartagener syndrome Neoplasm Headache, tension, or migraine

(Domino, 2014)

Differential Diagnosis

Occupation such as airline attendants or pilots Swimming and diving Barotrauma- barometric change in pressure that impairs sinuses and

clearance of secretions Smoking/fumes Allergies

(Porth, 2011)

Social/Environmental Considerations

Not routinely recommended and cannot differentiate between bacterial or viral (Domino, 2014).

Greater than or equal to 3 clinical findings have similar diagnostic accuracy as imaging (Domino, 2014).

CBC to detect leukocytes in acute sinusitis (not routine) (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Limited coronal CT scan can be used for recurrent infection or failure to respond to medical therapy (Domino, 2014).

MRI is reserved for suspected neoplasm or fungal sinusitis (Porth, 2010). Flexible fiberoptic rhinoscopy (Dunphy, Winland-Brown, Porter & Thomas,

2011).

Diagnostic

Most cases resolve with supportive care (tx pain and nasal symptoms). Antibiotics should be reserved for use after symptoms lasting greater than 10 days or worsening after 5-7 days.

(Domino, 2014)

Treatment

Decongestants Pseudoephedrine HCl Phenylephrine nasal spray (limited use) Oxymetazoline nasal spray – Afrin (don’t use > 3 days)

Analgesics Acetaminophen Aspirin NSAIDs Codeine (for severe cases)

Antibiotics (most people improve without therapy) Treat for 10-14 days Initial therapy

Amoxicillin: 1 gram 3x day (adults) 80-90 mg/kg/day total (q8hrs) Trimethoprim-sulfamethoxazole: 160/800 mg q 12 hr (adults) 8-12mg/kg/day total of TMP q 12hrs Doxycycline: 100 mg 2x day (adults only) (Domino, 2014)

Medications (First Line)

For patients whom have allergies as a factor, may benefits from: Oral antihistamines

Loratadine (Claritin) Fexofenadine (Allegra) Cetirizine (Zyrtec) Desloratadine (Clarinex) Levocetirizine (Xyzal) Diphenhydramine (Benadryl)

Leukotriene inhibitors Singular Accolade

Nasal steroids Fluticasone (Flonase) (Domino, 2014)

Medications

Only if pt has not responded to first line after 72 hours or has had abx in the past 4-6 weeks

Amoxicillin-clavulanate (Augmentin): 875/125 mg q 12 hrs (adult), 30 mg/kg/day q 12hrs (children)

High dose Augmentin XR twice a day in adults and Augmentin ES-600 in children Cefpodoxime (Vantin): 200 mg q12hr in adults, 10mg/kg/day q12hrs in children Cefuroxime axetil (Ceftin): 250 mg q12hr in adults, 30 mg/kg/day q12hr in children Azithromycin (Zithromax): 500 mg on day 1, 250mg days 2-5 in adults, 10mg/kg on day

1, 5mg/kg day 2-5 in children Clarithromycin (Biaxin): 500 mg BID or 1000mg/day (ER) in adults, 15mg/kg/day in two

doses for children Levofloxacin (Levaquin): 750mg/day for 5 days in adults only (Domino, 2014)

Medication (Second Line)

American Academy of Otolaryngology-Head & Neck Surgery Foundation recommend amoxicillin as first line therapy for most adults.

Infectious Disease Society of America recommends using Augmentin to treat for 5-7 days in uncomplicated adult cases and 10-14 days in uncomplicated children cases.

American Academy of Pediatrics recommends amoxicillin 45-90 mg/kg/day in two doses for uncomplicated cases and Augmentin 80-90 mg/6.4 mg/kg/day in two doses for severe cases.

(Domino, 2014)

Recommendations

Meningitis Orbital cellulitis Brain abscess Cavernous sinus thrombosis Osteomyelitis Subdural empyema Abnormal extraocular movements Protrusion of eyeballs (Domino, 2014)

Complications

Hydration Steam inhalation 20-30 minutes TID Saline irrigation Sleep with Hob elevated Avoid exposure to cigarette smoke or fumes Avoid caffeine and alcohol Analgesics, NSAIDs Educated that symptoms should improve within 72 hours and

complete resolution in 10-14 days (Domino, 2014)

Plan/Education

Return to office if no improvement after 72 hours or no resolution of symptoms after 10 days of antibiotics (Domino, 2014).

Return visit 10-14 days after initial assessment (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Immunocompromised patients should be monitored daily in an inpatient setting (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Follow-up

If no response after 3 weeks of antibiotics consider (Domino, 2014): CT scan of sinuses ENT referral

Referrals for surgical intervention to correct obstructions (polyps and deformities) if those with chronic sinusitis that is resistant to other therapy (Porth, 2011).

May also be referred to allergist or otolaryngologist (Dunphy, Winland-Brown, Porter & Thomas, 2011).

Consult/Referral

Possible interactions with warfarin can increase INR with macrlides or Bactrim, and you should stop statins temporarily with macrolides d/t increased risk of myopathy and rhabdomylosis.

Antibiotic contraindicated in pregnancy: clarithromycin, Antibiotic safe in lactation but not in pregnancy: Levofloxacin

Careful use with decongestants in hypertension d/t rebound nasal congestion

(Domino, 2014)

Considerations

461.0 Acute maxillary sinusitis 461.9 Acute sinusitis, unspecified 473.9 Unspecified sinusitis (chronic)

ICD-9 Codes

C - URI worsening after 5-7 days. Key word is bacterial Acute bacterial sinusitis shows

worsening s/s after 5-7 days and viral usually starts improving by the same time frame.

Which of the following findings is most consistent with the diagnosis of acute bacterial sinusitis?

A. Eyelid edema B. Facial swelling C. URI worsening after 5-7 days D. Greenish nasal drainage after 2

days

Question #1

B. S. pneumonia MRSA and anaerobic gram

negative bacilli are more common in chronic issues.

Influenza is a virus S. Pneumoniae is one of the most

common bacterial pathogens

What is the most common cause of acute bacterial sinusitis?

A. MRSA B. S. pneumonia C. anaerobic gram negative bacilli D. Influenza A

Question #2

D. wheezing Tooth pain, nasal discharge, and

fever can all be s/s of sinusitis.

Which of the following is inconsistent with the clinical presentation of sinusitis?

A. tooth pain B. yellow-greenish nasal discharge C. fever D. wheezing

Question #3

A. amoxicillin That is the first line in treatment

as long as there a no allergies to penicillin's or recent use of abx in the past 4-6 weeks.

Amoxicillin: 1 gram 3x day (adults) 80-90 mg/kg/day total (q8hrs)

Which antibiotic is a first line therapy in an adult with no recent antibiotic use?

A. amoxicillin B. levofloxacin C. clarithromycin D. trimethoprim-sulfamethoxazole

Question #4

D. high dose amoxicillin with clavulanate.

Amoxicillin-clavulanate (Augmentin): 875/125 mg q 12 hrs (adult), 30 mg/kg/day q 12hrs (children)

High dose Augmentin XR twice a day in adults and Augmentin ES-600 in children

Which antibiotic is appropriate in a patient who did not respond to therapy in the first 72 hours?

A. clindamycin B. vancomycin C. zosyn D. high dose amoxicillin with

clavulanate

Question #5

A. Bactrim Augmentin is a penicillin Vantin & Biaxin are second line

therapy Trimethoprim-sulfamethoxazole

(Bactrim): 160/800 mg q 12 hr (adults) 8-12mg/kg/day total of TMP q 12hrs

What would you prescribe in a patient that has a penicillin allergy?

A. Bactrim B. Augmentin C. Vantin D. Biaxin

Question #6

C. clarithromycin It is rate category C and may cause

miscarriages and major malformations.

Which antibiotic is contraindicated in pregnancy?

A. amoxicillin B. zithromycin C. clarithromycin

Question #7

All of these are objective findings of sinusitis in an exam.

Which is a clinical findings of sinusitis?

A. dental pain with percussion of sinuses

B. frontal sinus tenderness C. edema of turbinates D. all of the above

Question #8

D. all of the above These are all important pieces of

educating the patient.

Which should be included in patient education?

A. Steam inhalation B. Drink plenty of fluids C. Smoking cessation D. All of the above

Question #9

A. pets Nasal polyps, allergic rhinitis and

viral URI are all risk factors.

Which is not a risk factor for developing sinusitis?

A. pets B. nasal polyps C. allergic rhinitis D. viral URI

Question #10

Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B. & Blosser, C.G. (2013). Pediatric primary care (5th ed.). Elsevier, Philadelphia, PA.

Domino, F.J. (2014). The 5-minute clinical consult 2014 (22nd ed.). Lippincott, Williams & Wilkins, Philadelphia, PA.

Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company.

Porth, C.M. (2011). Essentials of Pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins

References