Transcript Acute Sinusitis - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
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© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
in the clinic
Acute Sinusitis
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What factors increase the risk for acute sinusitis?
Most common: Recent viral URI or allergies
 Asthma (Triad: asthma, nasal polyps, ASA intolerance)
 Age (old:  immunity,  URI, dry/weak nasal cartilage)
 Environmental irritants (smoke, chlorine)
 Atmospheric pressure changes (air travel)
 Dental/periodontal infection or sinus perforation during
tooth extraction
 Kartagener syndrome (sinusitis, bronchiectasis, dextrocardia)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What factors increase the risk for acute sinusitis?
Most common: Recent viral URI or allergies
 Cystic fibrosis
 Immune deficiency (AIDS, poorly controlled diabetes)
 risk fungal invasive sinusitis
 Autoimmune disease (Wegener granulomatosis)
 Facial injury or structural abnormality
deviated septum, nasal polyp
 Pregnancy
 Hospitalization (Abx or steroid Rxs, NG or ET tubes)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
How can patients decrease their risk for
acute sinusitis?
 Frequent hand-washing
 Avoid sick contacts
 Avoid allergens, irritants
(smoke, chemicals, strong
odors)
 Nasal corticosteroids,
immunotherapy (prevent
recurrent sinusitis in
allergic persons)
 Decongestant nose drops
(before air travel)
 Humidifier, steam
inhalation, nasal irrigation
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of the history and physical
exam in the diagnosis of acute sinusitis?
H&P  Basis for diagnosis
 No accepted office-based test
 Gold-standard: culture aspirate from antral puncture
(Not routine  painful, risks, requires expertise)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of the history and physical
exam in the diagnosis of acute sinusitis?
Primary Symptoms: Purulent rhinitis & facial pain (esp combo)
Other Signs & Symptoms
Check for:
 Nasal congestion or
obstructuction
 Swollen turbinates
 Postnasal drainage
 Nasal polyps
 Hyposmia or anosmia
 Sinus pain if bending over
 Ear pressure
 Oropharyngeal red streak
 Cough
 Worsening symptoms after
initial improvement
 Purulent rhinorrhea
Ask about:
 Allergies & other risk factors
 Symptom duration (<10 days
 unlikely bacterial)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
Why is it important to distinguish acute sinusitis
from chronic sinusitis?
Acute
 Cause: usually viral URI
 Duration: 1 - <4 wks
 Typically more severe
Chronic
 Cause: inflammation & blockage
(allergies, septal deviation,
polyps, tumors, foreign body)
 Duration: t >4 wks- years
 Chronic sinusitis
•Poor response to usual Abx Rx
•Longer Rx often needed
•Surgery if refractory to medical Rx
•Acute exacerbations
 Poorer response: severe allergies, structural changes from
chronic sinusitis itself or prior surgery)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What noninfectious conditions should clinicians
consider when evaluating for acute sinusitis?
 Allergic rhinitis
 Occupational rhinosinusitis
 Drug-induced rhinitis
(decongestant use >5 d,
cocaine)
 Gastroesophageal reflux
 Recurrent viral URIs
 Migraine/tension headache
 Nasal polyps (obstruction)
 Dental pain
Chronic sinusitis if symptom duration > 12 wks
 distinct differential dx
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of imaging in the diagnosis
of acute sinusitis?
 Imaging not routinely required or appropriate
 Not cost-effective c/w symptomatic Rx or criteria-guided Abx
 Xray evidence “sinusitis” in 87% viral URIs
 But <3% progress to bacterial infection
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of imaging in the diagnosis
of acute sinusitis?
Occipitomental view
 Sxs ≥ 7-10 d + Non-response/recur w/Rx
(Waters):
 Standard for paranasal
sinuses, esp maxillary
 Other conditions seriously considered
3 or 4 often ordered
Consider Xray :
 Risk of complications
(e.g., immunocompromised)
 Possible atypical microbe
(e.g., Pseudomonas aeruginosa, or
fungal infection w/ immunocompromise)
Positive radiographs:
 Sinus fluid/opacity
 Mucous membrane
thickening >50%
Consider CT/MRI :
 Possible local spread or intracranial complications
 Symptoms persist >3 wks despite Rx or recur
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of laboratory testing in the
diagnosis of acute sinusitis?
 Usually NOT needed
 If Rx non-response or worsening symptom: culture
Gold standard: Sinus puncture (maxillary)
 Invasive, risk of pain, bleeding, swelling, false passage
Alternative: Transnasal endoscopic culture
 Requires ENT: topical anesthetic, less invasive
Nasal swab / culture (direct swab thru nose)
 Poor correlation w/sinus pathogens
 Contamination w/normal nasal flora
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What is the role of laboratory testing in the
diagnosis of acute sinusitis?
 Other lab tests: depend on clinical situation
 CBC w/with differential
 TFT for fatigue
 Chloride testing for CF
 If sinusitis recurrent/persistent  refer for evaluation of
allergy/immune deficiency
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What organisms can cause acute
sinusitis?
Predominant isolates (>50% acute bacterial sinusitis)
Streptococcus pneumonia
Haemophilus influenzae
Other bacteria: Moraxella catarrhalis (esp children & young
adults) and Streptococcus pyogenes
H. influenzae
most
M. catarrhalis resistant to
Acute~⅓
fungal
sinusitis &
(less
common)
penicillin/amoxicillin 
Aspergillus
Production β-lactamase (H. influenzae, M. catarrhalis,
Staphylococcus aureus, Fusobacterium spp., and
Mucor
Prevotella spp.) or
Usually occur in immunocompromised
Changes in penicillin-binding protein (S. pneumoniae)
Fulminant invasive disease  high mortality if not treated
w/ more resistant
bacteria often need antimicrobial Tx
early,Pts
aggressively
(nasal surgery)
directed at all pathogens in mixed infections
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What nondrug measures are helpful in the
treatment of patients with acute sinusitis?
 Steam inhalation
 Hydration
 Sinus irrigation (e.g, neti pot)
 Increase mucosal
moisture, thin mucus, aid
sinus drainage
Remove inflammatory
debris & bacteria
How to Perform Nasal Irrigation
Salt-water solution:
1/2 tsp noniodinated salt
1/2 tsp baking soda
8-oz warm water
 Place in delivery device (e.g.,
neti pot, bulb syringe)
 Lean over sink, head down,
chin up
 Pour/squeeze water gently in
upper nostril (drains out other
nostril)
 Repeat on other side
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
How should clinicians decide whether to
use antibiotics to treat acute sinusitis?
 Antibiotic therapy appropriate if:
 High probability bacterial sinusitis
 Symptomatic Rx fails in low-probability patients
Probability of Bacterial Sinusitis
 ≥ 2: high probability (>50%)
 < 1: low probability (<25%)
URI >7 days
facial pain
purulent discharge (nasal, pharyngeal, or both)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
How should clinicians decide whether to
use antibiotics to treat acute sinusitis?
 Choice of Abx determined by circumstances
 Increased pneumococcal resistance to macrolides
 Trimethoprim–sulfamethoxazole acceptable 1st-line agent in
adults, but not recommended in children
 Broad-spectrum agents usually not necessary for 1st-line Rx
 Cephalosporins
 Fluoroquinolones
 More costly
 Concern promoting resistance
among bacteria in community & host
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
How should clinicians decide whether to
use antibiotics to treat acute sinusitis?
 Amoxicillin
 1st line agent
 Doxycycline

noifimprovement
afteror
3-5persistent
d, consider
 If
Use
penicillin allergy
symptoms
 Trimethoprim–sulfamethoxazole
alternative Abx
 Broader spectrum than amoxicillin
 Cephalosporins

Use if:
 AEs:
rash, GI symptoms, hypersensitivity
 Covers
β-lactamase–producing
H.
• Penicillin
allergy or persistentstrains
symptoms
reaction
(rare)
nd-line use (1st
2nd
-generation
(cefpodoxime)
for
2
influenzae,
M.
catarrhalis
• Pneumococcal resistance ≥24%
generation
minimal
efficacy against
S. pneumoniae,
 AEs:
Not for
GIchildren
upset,
neutropenia,
photosensitivity,
H.
influenzae)
notNo

rec’d
improvement
in childrenafter
≤8 y3-5 d, consider alternative

Caution if penicillin allergy
antibiotic
 AEs: GI upset, headache, rash, blood dyscrasias
 AEs: rash, GI symptoms, hematologic (rare),
toxic epidermal necrolysis (rare)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
How should clinicians decide whether to
use other drugs to treat acute sinusitis?
Nasal
steriods
 Reduces
mucosalbacterial
inflammation
 Initial
therapy in pts w/
low probability
disease
(fluticasone)
 May cause local irritation
OralRelieve
symptoms  For severe disease, reduces pain
corticosteroids
Oral
antihistamines
Anti-inflammatory,
helpful with allergic
 Restore
normal sinusenvironment
and function
(loratadine)
rhinitis
Nasal
Efficacy
varies, evidence
limited
decongestant
 Anti-inflammatory,
vasoconstriction(xylometazoline)
improves ostial drainage
 Avoid use for ≥3-5 d  risk for rebound
congestion
Systemic
decongestants
(pseudoephedrine)
 Caution if CVD, poorly controlled
hypertension, hyperthyroidism, diabetes
mellitus
Mucolytic agents
(guaifenesin)
 Reduces viscosity of nasal secretions
 May cause GI symptoms
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What are complications of acute sinusitis?
 Serious complications rare when managed properly
 Proximity of sinuses to CNS infection can become life
threatening if spreads: may require CT for Dx
 Intracranial: Extension into ostial/meningeal
structures (abscess)
 Orbital/Periorbital cellulitis: Orbital extension
(inflammation, abscess, blindness)
 Aneurysm/blood clot: Extension from sphenoid
sinus to carotid artery or cavernous sinus (may
be fatal)
 Nerve injury: Permanent loss of smell or taste
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
What are complications of acute sinusitis?
Clinical alerts
 Orbital swelling, conjunctival erythema,
limited extraocular movements
 Focal neurologic signs
 Altered mental status
 Abnormal culture on sinus puncture
 Exacerbation of asthma
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
When should clinicians consult a specialist?
 Complicated patients, severe symptoms, or nonresponsive
to initial therapy
 Otolaryngologist: When nonresponse to initial Rx or sinus
recurrent/chronic infections, or if anatomical abnormality
suspected
 Allergist: Underlying atopic disease, recurrent sinus
infections or symptoms persistent; treating sinus condition
improves asthma
 May require ophthalmologist, neurosurgeon, ID expert, or
neurologist, depending on symptoms
 Hospitalize with serious complications: orbital involvement,
infection or thrombosis of the intracranial venous sinuses,
or metastatic spread to CNS
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
Do special considerations exist for care of
patients with recurrent acute sinusitis?
Can be difficult to determine: Does recurrence
represent relapse or de novo episode?
 Reevaluate when
 Symptoms persist wks
 New or worsening symptoms
 Failure to improve may indicate
 Antibiotic resistance
 Significant allergic inflammation
 Fungal infection (rather than bacterial)
 Presence of complications
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
Do special considerations exist for care of
patients with recurrent acute sinusitis?
 Check for:
Persistent fever, sinus tenderness, purulent discharge,
change in mental status/vision
 Assess factors that could modify Rx:
Allergic rhinitis, anatomical variation, CF, ciliary dyskinesia,
immune compromise
 Imaging studies & bacterial cultures:
May guide Rx course & assess ? complications
 If no anatomical anomalies upon evaluation: Try 2nd-line
antibiotic therapy
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.
Are there practice guidelines relevant to
acute sinusitis?
 Joint Council of Allergy, Asthma, and Immunology
(2005): fungi  factor in chronic sinusitis
 American College of Chest Physicians (2006): Make no
dx in 1st wk symptoms
 American Academy of Otolaryngology—Head and Neck
Surgery Foundation (2007): Consider other causes,
complications when worse or no improvement 7 d after
dx and mgmt
 British National Institute for Health and Clinical
Excellence (2008): Use “No antibiotic or delayed
antibiotic strategy" for most
 Agency for Healthcare Research and Quality (2005):
Few studies compare efficacy newer antibiotics w/older,
less expensive ones
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 152 (9): ITC5-1.