Acute and Chronic Sinusitis

Objectives
•    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)




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



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


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


Sinusitis
•        4 paranasal sinuses, each lined with pseudostratified     ciliated columnar epithelium and goblet cells
–    Frontal   
–    Maxillary
–    Ethmoid
–    Sphenoid

 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


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


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


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


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


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



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



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



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


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


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


Diseases Slowing Ciliary Function
•    Allergic and nonallergic rhinitis
•    Rhinosinusitis
•    Aging rhinitis
•    Cystic fibrosis
•    Any disease causing obstruction, crusting of the mucosa


Causes of Mechanical Obstruction
•    Deviated nasal septum
•    Concha bullosa
•    Foreign body
•    Nasal polyps
•    Congenital atresia
•    Lymphoid hyperplasia
•    Nasal structural changes found in Downs syndrome



Vasculitides, Autoimmune and Granulomatous Diseases
•    Churg-Strauss vasculitis
•    Systemic lupus erythematosis
•    Sjogren’s syndrome
•    Sarcoidosis
•    Wegener granulomatosis


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


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


Physical Findings
•    Mucopurulent nasal discharge
–    Highest positive predictive value
•    Swelling of nasal mucosa   
•    Mild erythema
•    Facial pain (unusual in children)
•    Periorbital swelling


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!


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

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

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

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



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


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

•    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


•    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


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)


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

•    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


Rhinoscopy Aids in Diagnosing
•    Nasal polyps
•    Septal deviation
•    Concha bullosa
•    Eustachian tube dysfunction
•    Causes of  hoarseness
•    Adenoid hyperplasia
•    Tumors

MRI Imaging
•    Not used for imaging suspected acute sinusitis
•    Suspected fungal sinusitis
•    Suspected tumors


Bacteria Involved in Acute
Bacterial Sinusitis
•    Streptococcus pneumoniae     30%
•    Haemophilus influenza        20%
•    Moraxella catarrhalis        20%
•    Sterile                30%



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


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


Secondary Antibiotics for Acute Sinusitis
•    Cefdinir (Omnicef)
•    Cefuroxime (Ceftin)
•    Cephpodoxime (Vantin)
•    Azithromycin
•    Clarithromycin



Optimal Duration of Antibiotics

Give antibiotic until patient free of symptoms then add 7 days



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


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



Sx of Chronic Sinusitis
•    Nasal discharge
•    Nasal congestion
•    Headache
•    Facial pain or pressure
•    Olfactory disturbance
•    Fever and halitosis
•    Cough (worse when lying down)



Conditions Causing Chronic Sinusitis
•    Allergic and nonallergic rhinitis
•    Uncorrected anatomic conditions
•    Ciliary dyskinesia
•    Cystic fibrosis
•    Tumors
•    Immunodeficiency disorders
–    IgA, IgM
•    Granulomatous diseases



Evaluation of Chronic Sinusitis
•    CT or MRI scanning
–    Anatomic defects, tumors, fungi
•    Allergy testing
–    Inhalants, fungi, foods
•    Sinus aspiration for cultures
–    Bacterial
–    Fungal
•    Immunoglobulins



Treatment of Chronic Sinusitis
•    Nasal steroid spray
•    Guafenesin
•    Decongestants
•    Steam inhalation
•    Nasal  irrigation
•    Antibiotics with exacerbations



Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown
•    Streptococcus pneumoniae    
•    Haemophilus influenza       
•    Moraxella catarrhalis
•    Staph aureus       
•    Coagulase negative staphylococcus
•    Anerobic bacteria

               

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
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

   
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


Complications of Sinusitis
•    Orbital
–    Diplopia, proptosis
–    Periorbital erythema, swelling
•    Bone
–    Periosteal abscesses
•    Brain
–    Intracranial abscesses causing neurologic symptoms



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


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


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


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. 

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.

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
   

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



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


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 



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



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


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 System
Charlottesville, Virginia