Sinusitis resident survival guide

Sinusitis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis and Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.

Synonyms and keywords:approach to bacterial sinusitis, approach to viral sinusitis, approach to sinusitis, sinusitis workup, sinusitis management

Overview

Rhinosinusitis is the inflammation of the nasal mucosa and paranasal sinuses. The terms sinusitis and rhinosinusitis are used interchangeably, although rhinosinusitis is preferred because inflammation of the paranasal sinuses rarely ever occurs without concurrent inflammation of the nasal mucosa. The cause of rhinosinusitis is mostly infectious, although it can be associated with other medical conditions such as allergies. The diagnosis is primarily clinical and imaging and other diagnostic studies are not necessary for diagnosis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• There are no known causes of life-threatening causes of sinusitis.

Common Causes

Infectious causes of rhinosinusitis include viruses, bacteria, and fungi:

• Viruses
  • Rhinovirus
  • Influenza virus
  • Parainfluenza virus

• Bacteria
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Streptococcus pyogenes
  • Staphylococcus aureus: common in chronic sinusitis
  • Pseudomonas aeruginosa: common in nosocomial sinusitis, cystic fibrosis patients and the immunocompromised
  • Anaerobes: Prevotella, Fusobacterium and Peptostreptococcus: common in chronic sinusitis
• Fungi
  • Aspergillus species
  • Fusarium species
  • The Mucorales

Diagnosis and Treatment

• The diagnosis of sinusitis according to The Infectious Diseases Society of America is based on the presence of at least 2 major or 1 major and ≥2 minor of the following symptoms:

Sinusitis diagnosis criteria

Major symptoms	Minor symptoms
Purulent anterior nasal discharge	Headache
Purulent or discolored posterior nasal discharge	Otalgia, ear pressure, or fullness
Nasal congestion or obstruction	Halitosis
Facial congestion or fullness	Dental pain
Facial pain or pressure	Cough
Hyposmia or anosmia	Fatigue
Fever

• The clinical criteria for the diagnosis of bacterial sinusitis according to The American Academy of Otolaryngology, Head, and Neck Surgery is based on the fullfillment of all the following:
• Persistent symptoms
  • Nasal congestion, rhinorrhea, or cough
  • ≥10 days duration without improvement
• Severe symptoms
  • Temperature ≥38.5C for 3-4 days
  • Purulent rhinorrhea for 3-4 days
• Worsening symptoms
  • Return of symptoms after initial resolution
  • New or recurrent fever, increased rhinorrhea, or increase in cough

• Shown below is an algorithm summarizing the diagnosis and treatment of sinusitis according to the American Academy of Otolaryngology, Head, and Neck Surgery guidelines:

Adult with possible sinusitis

Duration ≤ 4w

Duration 4-12w

Duration ≥ 12w

No

Meets criteria for acute rhinosinusitis?

“Subacute” sinusitis excluded from guideline

Signs and symptoms of chronic rhinosinusitis?

No

Viral upper respiratory infection

Yes

Yes

Not chronic rhinosinusitis

No

Meets criteria for acute bacterial rhinosinusitis?

Yes

Acute bacterial rhinosinusitis

Documented sinonasal inflammation?

No

Viral acute rhinosinusitis

Yes

Complication suspected?

Yes

Obtain radiologic imaging

No

Chronic rhinosinusitis

Do not obtain radiologic imaging

Confirm the presence or absence of nasal polyps

No

Absense of complications?

Recommend symptomatic relief for acute bacterial rhinosinusitis

Recommend saline nasal irrigation and/or topical intranasal corticosteroids

Manage complication and acute bacterial rhinosinusitis

Offer watchful waiting OR prescribe antibiotic based on shared decision-making

Recommend saline nasal irrigation and/or topical intranasal corticosteroids

Do not prescribe topical or systemic antifungal therapy

Assess patient for chronic conditions that would modify management

Decision to proceed with watchful waiting

Decision to proceed with initial antibiotic therapy

Option of testing for allergy and immune function

Offer a safety-net or wait-and-see antibiotic prescription

Medical or surgical management as appropriate

Treatment failure

Yes

Prescribe amoxicillin, with or without clavulanate

No

Treatment failure?

Recurrent acute bacterial rhinosinusitis?

No

Yes

No

Exclude complications and other causes of illness; if diagnosis of acute bacterial rhinosinusitis is confirmed prescribe an alternate antibiotic

Management complete

• The diagnosis of sinusitis according to them is based on the presence of at least 2 major or 1 major and ≥2 minor of the following symptoms:

Sinusitis diagnosis criteria

Major symptoms	Minor symptoms
Purulent anterior nasal discharge	Headache
Purulent or discolored posterior nasal discharge	Ear pain, pressure, or fullness
Nasal congestion or obstruction	Halitosis
Facial congestion or fullness	Dental pain
Facial pain or pressure	Cough
Hyposmia or anosmia	Fatigue
Fever

Do's

• During retrieval of history, ask for the exposure to toxins, toxic waste, wood, immersion in contaminated water, solvents, gas or oil refineries, leather tanning, textiles, drug addictions, and chronic administration of intranasal drugs.
• During retrieval of history, ask for prior upper respiratory infections, use of tobacco, anatomic anomalies, acid reflux disease, and immunologic state.
• Look after major and minor signs of sinusitis:,
  • Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, and fever
  • Minor: headache, cough, halitosis, fatigue, otalgia, and dental pain
• During physical examination look for purulent nasal discharge, rhinolalia, edema, periorbital erythema, and pain to palpation and percussion to the front maxillary region.
• Be aware of orbital pain, visual disturbances, facial erythema, and meningitis signs, since these patients should be sent urgently to the emergency department.

Don'ts

• Avoid inappropriate use of antibiotics in acute presentations since the vast majority of these infections are viral.
• Avoid ordering imaging studies in cases where the diagnosis is well established clinically.
• Avoid the use of decongestants, antihistamines, topical steroid sprays when unnecessary.