Acute Rhinosinusitis

Definitions

  • Rhinosinusitis: symptomatic inflammation of nasal cavity and paranasal sinuses
    • Inflammation of the sinuses rarely occurs without concomitant nasal mucosal inflammation
  • Acute Rhinosinusitis: symptoms for <4 wks
  • Subacute Rhinosinusitis: symptoms for 4-12 wks
  • Chronic Rhinosinusitis (see Chronic Rhinosinusitis, [[Chronic Rhinosinusitis]]): symptoms for >12 wks
  • Recurrent Acute Rhinosinusitis: four or more episodes of acute rhinosinusitis per year (with intervening symptom resolution)

Epidemiology

  • Incidence: approximately 30 million cases per year in the US
    • Accounts for $3 billion in annual health care costs
    • Other costs include lost work productivity and impaired quality of life
  • Age: highest incidence in 45-74 y/o group
  • Sex: females > males
  • Microbial Etiologies: most cases of acute rhinosinusitis are due to viral infection

Microbiology

Viral

  • General Comments: most cases of acute rhinosinusitis are due to viral infection
  • Relative Prevalence of Viral Etiologies

Bacterial

Community-Acquired Acute Bacterial Rhinosinusitis

  • General Comments
    • Organisms Which are Considered Normal Upper Respiratory Tract Flora
    • Most Cases are Monomicrobial
      • Monomicrobial: 75% of cases
      • Two Microbes Isolated: 25% of cases
  • Anerobes: account for 7% of cases
    • Risk Factor: dental root infection with sinus invasion
  • Haemophilus Influenzae (see Haemophilus Influenzae, [[Haemophilus Influenzae]]): accounts for 35% of cases
  • Moraxella Catarrhalis (see Moraxella Catarrhalis, [[Moraxella Catarrhalis]]): accounts for 4% of cases
  • Streptococcus (see Streptococcus, [[Streptococcus]]): accounts for 7% of cases
    • Streptococcus Pyogenes (Group A Beta Hemolytic Streptococcus) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])
    • Streptococcus Pneumoniae (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]]): accounts for 41% of cases
  • Other Organisms: account for 4% of cases

Hospital-Acquired Acute Bacterial Rhinosinusitis

  • General Comments
    • Risk Factors
      • Blood in Sinuses on Admission
      • Burns (see Burns, [[Burns]])
      • Corticosteroid Therapy (ee Corticosteroids, [[Corticosteroids]])
      • Immobility
      • Intubation: especially nasotracheal intubation
      • Nasogastric Tubes/Nasotracheal Intubation/Nasal Packing
      • Obtundation (due to injury and/or sedation)
      • Prolonged Intensive Care Unit Stay
      • Supine Position
    • Microbiology: 56% of ICU-associated acute rhinosinusitis case are polymicrobial
  • Enterobacter (see Enterobacter, [[Enterobacter]])
  • Klebsiella Pneumoniae (see Klebsiella Pneumoniae, [[Klebsiella Pneumoniae]])
  • Proteus Mirabilis (see Proteus Mirabilis, [[Proteus Mirabilis]])
  • Pseudomonas Aeruginosa (see Pseudomonas Aeruginosa, [[Pseudomonas Aeruginosa]])
  • Serratia Marcescens (see Serratia Marcescens, [[Serratia Marcescens]])
  • Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])

Fungal


Physiology

Acute Viral Rhinosinusitis

  • Direct Contact with Viral Inoculation of Conjunctiva and/or Nasal Mucosa
    • Rapid viral replication in non-immune patient (with detectable viral levels within the viral mucosa within 8-10 hrs): symptoms usually develop within the first day after inoculation
    • Spread to paranasal sinuses by systemic or direct transmission: nose blowing may facilitate propulsion of contaminated fluid from nasal mucosa into the paranasal sinuses
    • Sinonasal hypersecretion, increased vascular permeability, and transudation of fluid into the nasal cavity and sinuses
    • Direct toxic effect of virus on nasal cilia -> impairs mucociliary clearance
    • Mucosal edema, thickened secretions, and ciliary dyskinesia -> sinus obstruction and perpetuation of the disease process

Acute Bacterial Rhinosinusitis

  • Bacterial Secondarily Infect an Inflamed Sinus Cavity
    • Etiologies of Inflamed Nasal Cavity
      • Allergic Rhinitis (see Allergic Rhinitis, [[Allergic Rhinitis]])
      • Impaired Mucociliary Clearance
        • Ciliary Dysfunction
        • Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]])
      • Immunodeficiency
      • Impairment of Sinus Drainage
      • Intranasal Cocaine Abuse
      • Mechanical Nasal Obstruction
      • Odontogenic Infection (Dental Abscess)
      • Preceding Viral Rhinosinusitis
      • Swimming

Diagnosis

  • Rhinoscopy: may demonstrate mucosal edema, narrowing of middle meatus, hypertrophy of the inferior turbinate, rhinorrhea, or purulent nasal discharge
  • Transillumination of Sinuses: limited diagnostic utility -> not recommended
  • Culture of Nasal Discharge or Swabs
    • Viral Culture: not indicated
    • Bacterial Culture: not generally utilized (since empiric therapy is usually adequate in the primary care setting)
  • Sinus Endoscopy: usually safely performed in otolaryngologist office
    • Indications for Endoscopic Culture of Middle Meatal Specimen
      • Cystic Fibrosis
      • Hospital-Acquired Rhinosinusitis
      • Immunocompromised Patient: especially if mucormycosis is suspected
      • Lack of Response to Antibiotic Therapy
      • Recent Hospitalization
      • Suspicion of Intracranial Extension: with vision changes, severe headache, peri-orbital edema, or alteration in mental status
  • Antral Sinus Puncture: no longer required
  • Sinus Computed Tomography (CT): imaging procedure of choice (when indicated)
    • Not indicated in the initial evaluation of uncomplicated acute rhinosinusitis
    • Sinus CT may be useful in ruling out acute rhinosinusitis, when other diagnoses are a consideration
    • Indications for Imaging
      • Recurrent/Treatment-Resistant Rhinosinusitis: to diagnose blockage of the ostio-meatal complex -> in this case, no contrast is required
      • Suspicion of Orbital/Intracranial Extension: with vision changes, severe headache, peri-orbital edema, or alteration in mental status -> in this case, contrast is required
    • Findings
      • Air Bubbles within the Sinuses
      • Sinus Air-Fluid Levels
      • Sinus Mucosal Edema
        • However, some form of sinus mucosal abnormality can be identified on CT in 42% of asymptomatic healthy persons
        • In patient with common cold, 87% manifested sinus air-fluid levels and/or mucosal thickening when assessed within 2-3 days of symptom onset
  • Sinus Magnetic Resonance Imaging (MRI): useful for patients with suspected extra-sinus extension

Clinical Manifestations of Acute Viral Rhinosinusitis (Common Cold)

General Comments

  • Definition: there is no universally accepted definition for the “common cold”
  • Epidemiology: during a single season, a single antigenic type of virus only accounts for <1% of colds

Otolaryngologic Manifestations

  • Eustachian Tube Dysfunction (see Eustachian Tube Dysfunction, [[Eustachian Tube Dysfunction]]): frequently associated
  • Hoarseness (see Hoarseness, [[Hoarseness]])
  • Nasal Discharge
  • Nasal Obstruction
  • Otitis Media (see Otitis, [[Otitis]]): occurs in 2% of cases in adults (and in a higher percentage of childhood cases)
  • Pharyngitis (see Pharyngitis, [[Pharyngitis]])
  • Scratchy Throat
  • Sneezing
  • Sinusitis: true symptomatic sinusitis is uncommon (although sinus mucosal thickening can often be demonstrated on sinus CT scans)
  • Vertigo/Viral Labyrinthitis (see Labyrinthitis, [[Labyrinthitis]]): may occur

Pulmonary Manifestations

  • Cough (see Cough, [[Cough]])

Other Manifestations

  • Fever (see Fever, [[Fever]]): less common
  • Chills: less common
  • Headache (see Headache, [[Headache]])
  • Malaise: less common
  • Myalgias (see Myalgias, [[Myalgias]]): less common

Natural Course

  • Progression Bacterial Rhinosinusitis: viral rhinosinusitis is complicated by bacterial rhinosinusitis in only 0.5-2% of cases
  • Resolution: uncomplicated viral rhinosinusitis usually spontaneously resolves in 7-10 days
    • Treatment does not shorten the course of the illness

Clinical Manifestations of Acute Bacterial Rhinosinusitis

General Comments

  • Differentiation of Acute Bacterial Rhinosinusitis from Acute Viral Rhinosinusitis: in general, the clinical presentation has limited accuracy in differentiating acute viral rhinosinusitis from acute bacterial rhinosinusitis
  • Clinical Features Suggesting the Diagnosis of Acute Bacterial Rhinosinusitis (Over Acute Viral Rhinosinusitis) (per the Infectious Disease Society of America, IDSA 2012 Guidelines -> however, the criteria have not been rigorously evaluated) [MEDLINE]
    • Persistent Symptoms of Acute Rhinosinusitis (Nasal Discharge/Fever/Headache/Facial Pain) Lasting at Least 10 Days without Evidence of Clinical Improvement
      • Although viral symptoms may persist for >10 days in some cases, there is generally some clinical improvement by day 10
      • However, in trials, only 60% of adults with symptoms for >7-10 days had a bacterial etiology identified by sinus aspirate
    • Onset of Severe Symptoms or High Fever (>39 degrees C/102 degrees F) and Purulent Nasal Discharge/Facial Pain at Least 3-4 Consecutive Days at the Beginning of the Illness
      • Fever associated with viral rhinosinusitis usually subsides in 24-48 hrs
      • Purulent nasal discharge associated with viral rhinosinusitis usually occurs 4-5 days into the illness
    • “Double-Sickening Pattern”: Onset of Worsening Symptoms/Signs (New Onset of Fever/Headache/Nasal Discharge) Following a Typical Viral Upper Respiratory Infection that Lasted 5-6 Days and Was Initially Improving

Otolaryngologic Manifestations

  • Anosmia/Hyposmia (Transient) (see Anosmia, [[Anosmia]])
  • Ear Pressure/Fullness
  • Facial Pain/Pressure (see Facial Pain, [[Facial Pain]]): worse with bending forward (this maneuver may be more sensitive than attempting to provoke by direct sinus percussion)
    • Presence of nasal congestion and facial pain/pressure are highly predictive of diagnosise of acute bacterial rhinosinusitis
  • Halitosis
  • Headache (see Headache, [[Headache]])
  • Maxillary Tooth Discomfort
  • Nasal Congestion/Obstruction: presence of nasal congestion and facial pain/pressure are highly predictive of diagnosis of acute bacterial rhinosinusitis
  • Purulent Nasal Discharge: presence of purulent rhinorrhea is highly predictive of diagnosis of acute bacterial rhinosinusitis

Other Manifestations

  • Cough (see Cough, [[Cough]])
  • Fatigue (see Fatigue, [[Fatigue]])
  • Fever (see Fever, [[Fever]]): may be the onyl sign in hospital-acquired cases

Complications

  • Anosmia (Permanent) (see Anosmia, [[Anosmia]])
  • Chronic Rhinosinusitis (see Chronic Rhinosinusitis, [[Chronic Rhinosinusitis]]): however, the relationship between acute rhinosinusitis and its potential for progression to chronic rhinosinusitis has not been well studied
  • Intracranial Epidural Abscess (see Intracranial Epidural Abscess, [[Intracranial Epidural Abscess]]): may be manifested by alteration in mental status, diplopia//vision changes
  • Meningitis (see Meningitis, [[Meningitis]])
  • Orbital Abscess/Cellulitis: manifested by peri-orbital edema
  • Sinus Bone Osteomyelitis

Treatment

Analgesics

  • Acetaminophen (Tylenol) (see Acetaminophen, [[Acetaminophen]]): indicated
  • Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) (see Non-Steroidal Anti-Inflammatory Drug, [[Non-Steroidal Anti-Inflammatory Drug]]): indicated
    • NSAID’s moderate the systemic symptoms of rhinovirus infection

Saline Irrigation

  • Mechanical Irrigation with Sterile Buffered/Physiologic/Hypertonic Saline: may decreased the need for analgesics and improve overall patient comfort (especially in patients with frequent sinus infections)
    • Use of tap water is contraindicated (due to risk of amebic encephalitis)

Removal of Nasal Devices

  • Removal of Nasogastric Tubes/Removal of Nasal Packing/Avoidance of Nasaotracheal Intubation: indicated in hospital-acquired cases

Topical Ipratropium (see Ipratropium, [[Ipratropium]])

  • Minimally absorbed across biologic membranes
  • Decreases rhinorrhea in viral rhinosinusitis (likely due to an effect on parasympathetic regulation of mucous and seromucous glands)

Topical Decongestants

  • Agents
  • Use
    • Use sparingly (no more than 3 consecutive days) to avoid rebound nasal congestion
    • May be useful for symptomatic relief in acute viral rhinosinusitis
    • Little benefit as an adjunctive therapy to antibiotics in acute bacterial rhinosinusitis

Oral Decongestants

  • Agents
    • Ephedrine (see Ephedrine, [[Ephedrine]])
    • Phenylephrine (Neosynephrine) (see Phenylephrine, [[Phenylephrine]])
    • Phenylpropanolamine (xxx) (see Phenylpropanolamine, [[Phenylpropanolamine]]): associated with an increased risk of hemorrhagic cerebrovascular accident (CVA)
    • Pseudoephedrine (Sudafed) (see Pseudoephedrine, [[Pseudoephedrine]]): improves nasal airflow in viral rhinosinusitis
  • Recommendations
    • May be beneficial to decrease mucosal edema, facilitate aeration, and promote nasal drainage in acute viral rhinosinusitis: when eustachian tube dysfunction is present, a 3-5 day course or oral decongestants may be indicated
    • Little benefit as an adjunctive therapy to antibiotics in acute bacterial rhinosinusitis

Topical Corticosteroids (see Corticosteroids, [[Corticosteroids]])

  • Rationale: corticosteroids decrease mucosal inflammation, improving sinus drainage
  • Studies: many studies are not well-controlled for disease process and treatment regimens
    • Meta-Analysis (2013): topical corticosteroids increase rate of symptom response (when used with or without concomitant antibiotics), as compared to placebo [MEDLINE]
  • Recommendations: greatest benefit is likely to occur in patients with underlying allergic rhinitis

Systemic Corticosteroids (see Corticosteroids, [[Corticosteroids]])

  • Studies
    • Systemic Review/Meta-Analysis (2011) [MEDLINE]: n = 4 randomized trials -> systemic corticosteroids with antibiotics improved symptom control at days 3-7, as compared to antibiotics with placebo (or in one trial, a non-steroidal anti-inflammatory)
    • Randomized Trial (2012) [MEDLINE]: systemic corticosteroids had no clinical benefit
  • Recommendations: not recommended until further high-quality trials are performed

Antihistamines

  • Rationale: mucosal drying effect (although this effect may worsen symptoms)
  • Recommendations: no trials support their clinical efficacy -> not recommended

Mucolytics

  • Rationale: thin secretions and may facilitate mucous drainage
  • Agents
    • Guaifenesin (Robitussin, Mucinex) (see Guaifenesin, [[Guaifenesin]])
  • Recommendations: no trials support their clinical efficacy

Antibiotics

Determination of Need for Antibiotics

  • Inappropriate Antibiotic Use: due to the difficulty distinguishing viral from bacterial acute rhinosinusitis, inappropriate antibiotic use has historically been common
    • In the US, 85-98% of patients receive antibiotics for upper respiratory or sinus infection (despite the vast majority of these representing viral rhinosinusitis, for which antibiotics are ineffective) [MEDLINE]

Data Supporting Efficacy of Antibiotics

  • Systematic Review (2012): n = 10 trials, patients with uncomplicated acute sinusitis and normal immune system): antibiotics slightly shortened the time to cure, but increased the incidence of adverse effects [MEDLINE]
    • Antibiotics are indicated in acute bacterial rhinosinusitis to eliminate infection and decrease the risk of complications

Agents

  • Amoxacillin-Clavulinic Acid (Augmentin) (see Amoxacillin-Clavulanic Acid, [[Amoxacillin-Clavulanic Acid]]): preferred first-line empiric agent
    • Dose: 500 mg/125 mg PO TID or 875 mg/125 mg PO BID
    • Indications for High-Dose Amoxacillin-Clavulanic Acid (2 g PO BID)
      • Age 65 y/o and Older
      • Immunocompromised
      • Recently Hospitalized
      • Residence in Geographic Region where Streptococcus Pneumoniae Have Penicillin-Resistance Rates >10%
      • Treated with Antibiotic in Previous Month
    • Pregnancy: Amoxacillin-Clavulinic Acid is class B -> acceptable
  • Doxycycline (see Doxycycline, [[Doxycycline]]): appropriate alternative agent
    • Pregnancy: contraindicated
  • Levofloxacin/Moxifloxacin (see Levofloxacin, [[Levofloxacin]] and Moxifloxacin, [[Moxifloxacin]]): appropriate alternative agent
    • Pregnancy: fluoroquinolones are contraindicated
  • Macrolides (Clarithromycin/Azithromycin)/Trimethoprim-Sulfamethoxazole/Second or Third-Generation Cephalosporins: not recommended for empiric therapy due to high rates of Streptococcus Pneumoniae resistance (and high rates of Haemophilus Influenzae resistance to Trimethoprim-Sulfamethoxazole)
    • Azithromycin would be acceptable alternative in a pregnant patient with penicillin allergy
  • Routine Coverage for Staphylococcus Aureus (Methicillin-Sensitive or Methicillin-Resistant): not recommended

Duration of Antibiotic Therapy

  • IDSA Guidelines [MEDLINE]: 5-7 day course (rather than 10-14 day course) is recommended in adults
    • Meta-Analysis (2009) [MEDLINE]: n = 12 randomized trials -> there was no difference in response/relapse rates between short courses (3-7 days) vs longer courses (6-10 days) of antibiotics

Treatment Failure

  • Expected Course of Clinical Improvement on Antibiotics: patients with acute bacterial rhinosinusitis are expected to demonstrate response to empiric antibiotics within 3-5 days
    • Experimental evidence indicates bacterial eradication by day three: studies have correlated clinical and bacteriologic response
  • Reasons for Treatment Failure
    • Inadequate Antibiotic Dosing
    • Non-Infectious Etiology
    • Resistant Pathogen
    • Structural Abnormality
  • Recommendations
    • Ideally, an endoscopically-guided culture could be performed to redirect antibiotic therapy (note: nasopharyngeal cultures are not reliable)
    • Total course duration of 7-10 days is recommended
    • CT scan of the sinuses is indicated if symptoms worsen or fail to improve
  • Second-Line Agents

Relapse After Treatment

  • Recurrence Within 2 wks of Response to Initial Treatment: usually represents inadequate eradication of infection
    • Patients with good response to initial therapy and who have mild symptoms of relapse: treat with a longer course of the same antibiotic
    • Patients who had only minimal symptom response with the initial antibiotic or whose relapse is moderate to severe: more likely to have organisms resistant to the initial empiric antibiotic and require a change in antibiotic

Indications for ENT Referral

  • Patients with Suspected Extra-Sinus SpreadL characterized by high/persistent fevers, meningeal signs, visual disturbance, orbital edema, severe headache, or altered mental status
  • Patients with Suspected Mucormycosis: patients require urgent endoscopy or surgical biopsy
  • Patients with Hospital-Acquired Acute Bacterial Rhinosinusitis
  • Patients with Identified Structural Defects
  • Patient with Lack of Response to First/Second-Line Therapy
  • Multiple Recurrent Episodes of Acute Bacterial Rhinosinusitis (3-4 episodes per year)
  • Chronic Rhinosinusitis (with or without Polyps or Asthma) with Recurrent Exacerbations of Acute Bacterial Rhinosinusitis
  • Patients with Allergic Rhinitis who May be Candidates for Immunotherapy

Surgery


References

  • Nosocomial sinusitis. JAMA 1982; 247:639-641
  • Upper respiratory tract infections in the critically ill. J Intensive Care Med 1990; 5:129-152
  • The evaluation of fever in the intensive care unit. Chest 1991; 100:213-220
  • Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial. Crit Care Med 1993; 21:1132-1138
  • Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. 2001 Mar 20;134(6):498-505 [MEDLINE]
  • Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009;67(2):161 [MEDLINE]
  • Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008115. doi: 10.1002/14651858.CD008115.pub2 [MEDLINE]
  • Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;10:CD006089 [MEDLINE]
  • Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ. 2012 Oct;184(14):E751-7. Epub 2012 Aug 7 [MEDLINE]
  • IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Infectious Diseases Society of America. Clin Infect Dis. 2012;54(8):e72 [MEDLINE]
  • Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;12:CD005149 [MEDLINE]