FIGURE 15–1. Purulent discharge from middle meatus indicates acute rhinosinusitis.
FIGURE 15–2. A swab is introduced into the middle meatus to obtain purulent discharge for bacterial culture.
• Specimens from the nasal floor and nasopharynx are prone to contamination with poor correlation with the etiological pathogen.
• Plain films are of little diagnostic value due to low sensitivity and specificity; this is especially true in children whose paranasal sinuses are not well pneumatized.
• CT, MRI, and ultrasound are not routinely used or recommended except in the presence of complications, immune compromise, and very severe disease. CT is useful for providing a road map for endoscopic sinus surgery in indicated cases; anatomic abnormalities such as infraorbital air cell, concha bullosa, and septal deviation that potentially predispose to rhinosinusitis should be evaluated. MRI is the best imaging modality when intracranial and orbital complications are suspected.
• Maxillary sinus puncture and aspiration is the gold standard for definite diagnosis and for obtaining specimen for bacterial culture, but this procedure is invasive and requires a skilled specialist to perform safely and reliably.
Acute Bacterial Rhinosinusitis
• Key symptoms of bacterial rhinosinusitis are purulent nasal discharge and local facial pain or dental pain. Important signs of bacterial rhinosinusitis are fever, after typical duration of viral illness, and purulent discharge observed at middle meatus or posterior nasal drip.
• According to guidelines from the American Academy of Otolaryngology, certain symptoms of acute rhinosinusitis suffice to diagnose ABRS: those that either persist at least 10 days or clinically worsen (so-called “double worsening”) after a typical duration of viral illness within 10 days from the onset.
• According to the 2012 European position paper, on rhinosinusitis and nasal polyps (“EPOS”), the diagnosis of ABRS requires worsening symptoms after 5 days or persistent symptoms after 10 days with at least an additional three of the five following criteria: fever ≥38°C, discolored nasal discharge (with unilateral predominance), local facial pain (with unilateral predominance), elevated ESR or CRP, double worsening.
• According to the 2012 guidelines from the Infectious Diseases Society of America (IDSA) on clinical practice for acute bacterial rhinosinusitis in children and adults, the diagnosis of ABRS requires at least one of three of the following criteria: persistent symptoms for more than 10 days, onset of severe symptoms present at the beginning of illness (fever ≥39°C and purulent nasal discharge or facial pain), double worsening.
• Definitive diagnosis is the presence of 100,000 colony-forming units of pathogen per milliliter from antral puncture culture; however, the culture yield is largely dependent on sterile techniques, as contamination easily occurs.
• Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the three most common causative agents. S. pneumoniae has decreased from the most frequent pathogen (38%) to approximately now being the same as that of H. influenzae (36%) possibly due to the increasing use of pneumococcal vaccine; additionally, Staphylococcus aureus is also found in about 10% of the cultures.
• The goal of treatment is to stop the inflammatory process and to relieve symptoms. The majority of cases are caused by a virus and the disease is self-limiting; patients need only symptomatic medications without antibiotics, except when superimposed bacterial infection occurs.
Intranasal Corticosteroid (INCS)
• The aim of INCS is to reduce inflammation of the nasal mucosa and the sinus ostium. This helps facilitate sinus clearance, normal ciliary function, and ventilation.
• It is recommended as monotherapy for VRS, especially in non-severe cases; as an adjunct therapy in ABRS, combining with antibiotics is beneficial to facilitate faster symptom reduction.
• A 2005 study from Meltzer, Bachert, and Staudinger concluded that double-dosing (twice daily) INCS is more effective than regular (once daily) dose.
• Oral steroid is not recommended as monotherapy in acute uncomplicated rhinosinusitis—a placebo-controlled study in 2012 did not show any difference from placebo; however, combining oral steroid with antibiotics might reduce facial pain and nasal congestion in ABRS patients.
• Antibiotics are the mainstay treatment in ABRS; Ahovuo-Saloranta and colleagues stated in 2014 that efficacy among different antibiotics are not significantly different.
• Some ABRS patients recover without antibiotics; with good ability to follow up, “watchful waiting” may be offered to uncomplicated ABRS cases regardless of severity. According to the American Academy of Otolaryngology guidelines, antibiotics are considered optional. If symptoms are not improved within 7 days or patient’s conditions worsen within 48 to 72 hours, then antibiotics should be started.
• The choice of antibiotics is based on suspected pathogens, individual and community risk of resistant strains, immune status, antibiotic properties, tolerability, and cost.
• The first-line therapy should be narrow-spectrum antibiotics with high effectiveness, low adverse events, and low cost. Amoxicillin with or without clavulanate is one suitable antibiotic
• High-dose amoxicillin formulation (90 mg/kg/day) should be considered in suspected cases of drug-resistant S. pneumoniae due to its penicillin-binding protein-3 mutation. The prevalence of strains is geographically different; however, risks must be considered under certain conditions: <2 years or >65 years of age, systemic toxicity (fever ≥39°C, impending suppurative complication), attendance at daycare, prior use of antibiotics, recent hospitalization, or poor immune status. The downsides are the additional cost and potentially more adverse side effects.
• The second-line antibiotics are doxycycline and levofloxacin/moxifloxacin.
• In patients with penicillin allergy, alternatives can be prescribed: doxycycline, levofloxacin/moxifloxacin, and clindamycin plus third-generation cephalosporin (in cases of non-type I hypersensitivity to penicillin).
• The FDA has issued a black box warning for quinolone antibiotics with potentially “disabling side effects involving tendons, muscles, joints, nerves, and the central nervous system,” recommending they be reserved for treatment of rhinosinusitis “when there are no other options available.”
• Antibiotics are given for 5 to 7 days in adults and 10 to 14 days in children.
• Evidence shows no difference between short (5 days) versus long (10 days) courses of antibiotics; however, long courses are associated with more side effects, higher cost, and poorer compliance.
• Oral antihistamines are only recommended for symptom relief for those who have concomitant allergic rhinitis.
• Evidence for antileukotrienes, oral decongestants, topical decongestants, and mucolytic drugs in ARS is still lacking.
• Saline irrigation helps to relieve symptoms, facilitates pus removal, and promotes ciliary function.
• There is no supportive evidence for steam inhalation, probiotics, or vitamin C in acute rhinosinusitis.
• Generally, acute rhinosinusitis does not require surgical intervention; however, in a complicated case such as with orbital and intracranial complications, endoscopic sinus surgery (ESS) is considered definitive treatment.
• Criteria for orbital complication requiring ESS are subperiosteal abscess with either no response to appropriate intravenous antibiotics for at least 24 to 72 hours or deterioration of visual acuity. In cavernous sinus thrombosis, ESS contributes to treatment by facilitating the removal of the source of infection.
• Antral puncture may be indicated for two reasons: one is to obtain bacterial culture for either definitive diagnosis in clinical research or for antibiotic selection; the other is to relieve the pain of maxillary sinusitis when followed by antral irrigation.
• Adenoidectomy is not warranted for a single episode of ARS. Evidence shows benefits in recurrent acute sinusitis cases, especially if accompanied by obstructive symptoms like adenoid hypertrophy with otitis media or obstructive sleep apnea.
• Balloon sinuplasty has no role in ARS; however, small case series have shown good outcomes when combined with aggressive antibiotics in critically ill and immunocompromised patients.
• Procedures such as nasoantral windows, inferior antrostomies, and Caldwell-Luc operations do not have proven benefit in treating the disease.
• ARS is an inflammatory condition, mainly resulting from a virus, and is essentially self-limited.
• Antral puncture with aspiration is the gold standard for collecting reliable bacterial cultures.
• Intranasal corticosteroid is a standard treatment for uncomplicated ARS and should be combined with antibiotics for ABRS.
• Antibiotics are effective for ABRS; however, “watchful waiting” is acceptable and should be considered in uncomplicated cases.
• Surgical intervention like endoscopic sinus surgery is reserved for complicated cases.
• Figure 15–3 presents a brief algorithm of diagnosis and treatments for ARS.
FIGURE 15–3. Algorithm for diagnosis and treatment of acute rhinosinusitis. Abbreviations: URI, upper respiratory tract infection; VRS, viral rhinosinusitis; ABRS, acute bacterial rhinosinusitis; INCS, intranasal corticosteroid; IV, intravenous.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
