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I.
OBJECTIVES
a. To define rhinosinusitis and describe its epidemiology
b. To differentiate acute from chronic rhinosinusitis
c. To enumerate the different etiologies of rhinosinusitis
d. To describe the clinical presentation of rhinosinusitis
e. To discuss the appropriate antimicrobial therapy for sinusitis
II.
CASE SCENARIO
A teenage boy is brought to the clinic for two weeks severe nasal congestion, thick
yellow mucoid discharge, and undocumented fever unrelieved by over-the-counter
cold and flu medications. He had facial pain and headache for one week, worsened by
changes in head position, coughing, and straining. Inspection reveals conjunctival
injections and a hyperemic external nose. His forehead, nasal bridge, and cheeks are
warm and tender to palpation. Rhinoscopy shows congested, edematous turbinates
obstructing nasal airflow, and yielding mucopurulent material from the lateral nasal
walls on decongestion.
III.
EPIDEMIOLOGY
Sinusitis / Acute Rhinosinusitis
Refers to an inflammatory condition involving the four paired structures
surrounding the nasal cavities.
Develops when natural drainage of the paranasal sinuses is affected by nasal
inflammation or pathology.
Most cases are diagnosed in the ambulatory care setting and occur primarily
as a consequence of a preceding viral upper respiratory infection.
Typically classified by:
o Duration acute vs. chronic
o Etiology infectious vs. non-infectious
o Pathogen viral, bacterial, or fungal
Most cases involve more than one sinus.
Sinuses involved, in order of frequency:
o Maxillary
o Ethmoid
o Frontal
o Sphenoid
Vicious cycle resulting to rhinosinusitis:
o Altered mucociliary clearance
o Retained secretions
o Ostiomeatal unit obstruction
Sinusitis affects a tremendous proportion of the population, accounts for
millions of visits to primary care physicians each year, and is the fifth leading
diagnosis for which antibiotics are prescribed.
IV.
V.
ETIOLOGY
Non-infectious causes:
o Allergic rhinitis with either mucosal edema or polyp obstruction
o Barotraumas from deep-sea diving or air travel
o Exposure to chemical irritants
o Nasal and sinus tumors squamous cell carcinoma
o Granulomatous diseases Wegeners or rhinoscleroma
o Conditions leading to altered mucus content through impaired mucus
clearance cystic fibrosis
Major risk factors for nosocomial sinusitis
o Nasotracheal intubation
o Nasogastric tubes
Viral rhinosinusitis is far more common than bacterial sinusitis
o Most commonly isolated:
Rhinovirus
Parainfluenza virus
Influenza virus
Bacterial causes of sinusitis have been better described.
o Community-acquired
Streptococcus pneumoniae and Haemophilus influenzae
Most common pathogens; 50 60% of cases
2
VI.
VII.
Azithromycin
Clarithromycin
o US FDA-approved drugs for the treatment of acute sinusitis:
Cefuroxime, cefpodoxime
Clarithromycin, azithromycin
Levofloxacin
Antibiotic treatment should be started earlier (before 7 days) for patients
with:
o Anatomical blockage nasal polyps, severe septal deviation
o Recurrent sinusitis
Patients with severe symptoms requiring emergent care:
o Visual disturbances
o Orbital pain
o Periorbital swelling or erythema
o Facial swelling or erythema
o Signs of meningitis or cavernous sinus thrombosis (worst headache of
my life)
Intranasal corticosteroids
o Recommended as twice-daily monotherapy for moderate ARS
o In combination with oral antibiotics for severe ABRS
Antihistamines are only indicated in the presence of underlying allergic
rhinitis.
Adjunctive therapy:
o Topical congestants
Have efficacy in symptom control
Decongest the inferior and middle turbinates and infundibular
mucosa
Have anti-inflammatory and anti-oxidant effects
Improve mucociliary transport
o Physiologic or hypertonic intranasal saline irrigation has a limited
effect on adults with ARS
All patients treated for ABRS should be reevaluated before the 10-day
antibiotic course ends, and those with persistence after seven days or
worsening disease after three to five days should be evaluated by an ENT
specialist.
IX.
X.
XI.
CASE RESOLUTION
The teenage boy had severe acute bacterial rhinosinusitis without nasal polyposis that
persisted despite twice-daily oxymetazoline 0.05% nasal decongestion, saline
douches, and thrice-daily high-dose amoxicillin. A shift to co-amoxiclav after two
days improved his condition which resolved in a week. Antibiotics were continued
for another week, with a final evaluation scheduled before the completion of the full
course of treatment.