4.2 Rhinosinusitis
4.2.1 Acute Rhinosinusitis
Key Features
Rhinosinusitis is an inflammatory condition of the nose and sinuses.
By definition of acute, signs and symptoms last less than one month.
The condition resolves with treatment; inadequate treatment may lead to disabling chronic disease.
Acute bacterial rhinosinusitis is frequently managed by primary care providers. The otolaryngologist often sees patients who are inadequately treated or who have recurrent disease. Aggressive care is necessary with immunocompromised patients. Collection of mucopus during nasal endoscopy enables one to obtain data for culture-directed antibiotic therapy. Treatment is usually medical, in the absence of orbital or intracranial complications.
Epidemiology
True incidence is difficult to establish because of some overlap with other complaints, such as upper respiratory infection or allergy. However, rhinosinusitis is among the most common of all healthcare complaints. Rhinosinusitis (all varieties) is reported to affect 31 million people in the United States. An estimated 20 million cases of acute bacterial rhinosinusitis occur annually in the United States. Annual U.S. expenditure related to the primary diagnosis of sinusitis totals approximately $3.5 billion.
Clinical
Signs and Symptoms
Acute rhinosinusitis may be suspected based on signs and symptoms. Major factors include facial pain or pressure, congestion or fullness, nasal obstruction, nasal discharge, purulence, or discolored postnasal drainage, hyposmia/anosmia, purulence in nasal cavity on exam, and fever. Minor factors include headache, fatigue, halitosis, dental pain, cough, and ear pain or ear pressure/fullness.
Updated guidelines have simplified diagnostic criteria: purulent drainage with nasal obstruction and facial pain/fullness/pressure persisting 10 days, or worsening within 10 days after initial improvement. Fever is relatively specific to acute rhinosinusitis versus other forms of sinonasal disease. Localizing symptoms may suggest specific paranasal sinus involvement: cheek or upper dental pain with maxillary sinusitis, forehead pain, or frontal headaches with frontal sinusitis. Retro-orbital or occipital pain may be seen with sphenoid sinusitis. Pervasive sinus disease can, however, remain occult with nonspecific symptoms.
Differential Diagnosis
In the early phase of the disease (first 10 days), the etiology is presumed to be viral. Thus, a typical viral upper respiratory infection is the main alternative diagnosis in the patient with a history of symptoms of less than 2 weeks’ duration. Other entities to be considered include allergic rhinitis exacerbation, unrecognized chronic rhinosinusitis, or rare nasal manifestations of systemic disease such as limited Wegener′s granulomatosis or sarcoid. Other causes of localized symptoms include severe periodontal disease or recurrent migraine, which may include throbbing localized headache as well as nasal congestion. In the immunocompromised patient, a high index of suspicion for invasive fungal rhinosinusitis is critical.
Evaluation
The diagnosis is generally made on the basis of signs and symptoms, by history in combination with objective exam findings. Occasionally, radiographic assessment is needed.
Physical Exam
A full head and neck examination is performed, including a cranial nerve exam. It is important to exclude evidence of complicated sinusitis, such as orbital or intracranial extension of disease. Therefore, note is made of proptosis, periorbital edema, extraocular motility, tenderness, and meningeal signs. Guidelines recommend anterior rhinoscopy or nasal endoscopy; nasal endoscopy is more informative. Assessment includes position of the septum; presence of mucosal edema; presence, location, and quality of mucus or purulence; and the presence and quality of polyps or masses. A calcium alginate swab (Calgiswab, Puritan Medical Products, Guilford, ME) or suction trap can be easily used to obtain a sample of any purulence endoscopically from the sinus ostia or middle meatus for culture and sensitivities, especially in recurrent sinusitis or previous antibiotic failure.
Imaging
The diagnosis of uncomplicated acute rhinosinusitis is generally made on history and exam. If complications or alternative diagnoses are suspected, thin-section noncontrast coronal and axial computed tomography (CT) scanning of the paranasal sinuses is the most useful study. The presence of fluid- or soft tissue–density opacification of a paranasal sinus is diagnostic. Mucosal thickening without obvious fluid suggests chronic disease. The bony detail of the skull base and orbits should be assessed. Bone erosion or thickening, or the presence of a sinonasal mass, suggests other than acute rhinosinusitis and will prompt additional work-up.
The utility of plain X-ray films is very limited. Disease of the middle meatus, infundibulum, frontal recess, anterior ethmoidal air cells, and superior nasal cavity is not identifiable. Furthermore, the radiation exposure from a screening sinus CT (i.e., limited cuts) is probably comparable to that from a plain film series.
Labs
Unless the patient is toxic or immunosuppressed, or one suspects complications of acute rhinosinusitis (orbital or intracranial extension), blood work such as a complete blood count (CBC) with differential is not helpful. Testing for allergy and immune function is considered with recurrent acute rhinosinusitis or chronic disease.
Microbiology
It is generally accepted that viral infection predominates for the first 10 to 14 days and then leads to sinus ostia obstruction. Inspissated mucus leads to bacterial infection. The most common organisms are Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis as well as anaerobes and other Streptococcus species. Drug resistance is a growing problem.
Treatment Options
Uncomplicated acute rhinosinusitis is observed or treated medically. If symptoms persist beyond 7 to 10 days, bacterial infection is more likely and antibiotics are indicated. The typical duration of therapy is 5 to 10 days. Adult empiric therapy published guidelines recommend (a) amoxicillin/clavulanate (1.75–4.0 g/250 mg per day, or 875 mg twice daily), (b) amoxicillin (1.5–4 g/d, or 500 mg three times daily), or (c) cefuroxime axetil (250 mg twice daily). In β-lactam-allergic patients, guidelines recommend (a) trimethoprim–sulfamethoxazole double-strength (twice daily); (b) doxycycline (100 mg twice daily); or (c) macrolide therapy ( Table 4.6 ). If there is no improvement in 72 hours, or if there has been antibiotic use within the previous 4 to 6 weeks, the antibiotic should be switched; consider fluoroquinolone, ceftriaxone, or clindamycin. If possible, antibiotic therapy should be culture-directed at this point.
In pediatric patients, guidelines recommend (a) amoxicillin/clavulanate (90 mg/6.4 mg/kg per day), (b) amoxicillin (45–90 mg/kg per day), or (c) cefuroxime axetil (generally 30 mg/kg per day divided every 12 hours; maximum 1,000 mg daily). In β-lactam-allergic patients, guidelines recommend trimethoprim–sulfamethoxazole (6–10 mg trimethoprim per kg per day divided every 12 hours), or a macrolide such as clarithromycin (15 mg/kg per day divided every 12 hours).
Additional medical therapy involves the use of oral decongestants such as pseudoephedrine (30–60 mg every 6 hours as needed). Caution should be used in patients with prostatic hypertrophy or poorly controlled hypertension. Topical decongestants such as oxymetazoline 0.05% (two sprays each nostril twice daily) can be used for 3 to 5 days at most to facilitate drainage. Prolonged use will cause rhinitis medicamentosa. Oral antihistamines are indicated only if the symptoms are associated with allergy exacerbation. Topical nasal steroids have been recommended recently to help decrease inflammation and to play a prophylactic role following resolution of symptoms in patients with recurrent disease. Nasal saline is useful for thinning secretions, as is guaifenesin (600–1,200 mg twice daily).
Occasionally, maxillary puncture is necessary to obtain material for culture and/or to relieve severe symptoms. This may be done via the inferior meatus or canine fossa. A common indication for this is an immunocompromised patient on multiple recent antibiotics with an occluded sinus.
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