Difference between revisions of "Sinusitis"

(Background)
(<10 days of symptoms)
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==Background==
 
==Background==
 +
*Viral source is by far most common. Bacterial infection accounts for only 0.5-2% of all cases<ref name="Fokkens">Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar;(23):3 p preceding table of contents, 1-298</ref>
 +
**Other causes include allergies and fungal infection
 +
*Timeframe
 +
**Acute (<4 weeks)
 +
**Subacute (4-12 weeks)
 +
**Chronic (>12 weeks)
  
Rhinosinusitis - Inflammation of the lining of the paranasal sinuses
+
==Clinical Features==
 +
*Defined as 2 or more of the following:
 +
**Blockage or congestion of nose
 +
**Facial pain or pressure
 +
**Hyposmia (diminished ability to smell)
 +
**Anterior or posterior nasal discharge lasting <12wk
 +
*Additional symptoms:
 +
**Tooth pain
 +
**Fever
 +
**Sinus pressure while bending forward to changing head position
  
#Acute (< 4 weeks)
+
==Differential Diagnosis==
##Acute viral
+
{{Rhinorrhea}}
##Acute bacterial (0.5-2% of cases)
 
#Subacute (4-12 weeks)
 
#Chronic (>12 weeks)
 
#Other causes
 
##Fungal infections
 
##Allergies
 
  
==Diagonsis==
+
{{Headache DDX}}
  
{| style="width: 581px; width="437" border="1"
+
==Evaluation==
| style="width: 581px; height: 14px" colspan="3" width="437" valign="top" |
+
*Clinical diagnosis
'''Classic History & Physical'''
+
*Consider CT only for toxic patients (to rule-out complication)
|-
 
| style="width: 156px; height: 15px" width="117" |
 
<center>'''Feature'''</center>
 
| style="width: 87px; height: 15px" width="66" |
 
<center>'''Viral'''</center>
 
| style="width: 338px; height: 15px" width="254" |
 
<center>'''Bacterial'''</center>
 
|-
 
| style="width: 156px; height: 15px" width="117" |
 
Duration (symptoms)
 
| style="width: 87px; height: 15px" width="66" |
 
<center><10<span style="display: none; line-height: 0"></span>days</center>
 
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<center>Usually >10 days OR worsening symptoms within 10 days after initial improvement</center>
 
|-
 
| style="width: 156px; height: 29px" width="117" |
 
Color change (nasal discharge)
 
| style="width: 87px; height: 29px" rowspan="5" width="66" |
 
<center>+/−</center>
 
| style="width: 338px; height: 29px" width="254" |
 
<center>+++, quality usually yellow-green and thick</center>
 
|-
 
| style="width: 156px; height: 14px" width="117" |
 
Maxillary dental pain
 
| style="width: 338px; height: 14px" width="254" |
 
<center>+++, often unilateral and associated with a particular sinus</center>
 
|-
 
| style="width: 156px; height: 14px" width="117" |
 
Postnasal drip
 
| style="width: 338px; height: 14px" width="254" |
 
<center>More common</center>
 
|-
 
| style="width: 156px; height: 15px" width="117" |
 
Fever, cough, fatigue
 
| style="width: 338px; height: 15px" width="254" |
 
<center>More common</center>
 
|-
 
| style="width: 156px; height: 14px" width="117" |
 
Hyposmia/anosmia
 
| style="width: 338px; height: 14px" width="254" |
 
<center>More common</center>
 
|}
 
  
== Basic Management ==
+
===IDSA Guidelines 2012<ref>Chow AW et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Disease (2012) 54:e72-112.</ref>===
 +
*Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
 +
*Concern for bacterial (treat with antibiotics) if any of these:
 +
**Purulent discharge and pain on face or teeth > 10 days without improvement
 +
**Severe symptoms or fever > 39 plus symptoms > 3 days
 +
**"Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days
  
< 10 days symptomatic treatment b/c most likely viral
+
==Management==
 +
===<10 days of symptoms===
 +
*Symptomatic treatment:
 +
**Analgesia
 +
**Mechanical irrigation with buffered, hypertonic saline
 +
**OTC decongestants
 +
**Intranasal decongestants (e.g. [[oxymetazoline]] for no more than 3 days)
 +
**Intranasal corticosteroids (e.g. [[mometasone furoate]] monohydrate, [[Flonase]])<ref>Trestioreanu AZ, Yaphe J. "Intranasal steroids for acute sinusitis." The Cochrane Database of Systematic Reviews. 2 December 2013. DOI: 10.1002/14651858.CD005149.pub4</ref>
 +
*Avoid antibiotics (Part of [[Choosing wisely ACEP|ACEP Choosing wisely]])
  
*Analgesia
+
===>10 days of symptoms===
*Mechanical irrigation with buffered, hypertonic saline
+
*Possible bacterial source, especially if associated with:
*Topical glucocorticoids
+
**No clinical improvement after 10 days
*Topical decongestants (e.g., oxymetazoline for no more than three days)
+
**Severe symptoms or high fever and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness
*Antihistamines
+
**Onset with newly worsening that were initially improving (‘‘doublesickening’’)
*Mucolytics
+
*Acute bacterial sinusitis<ref>Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. IDSA Guidelines. 2012; Clinical Infectious Diseases e1-e41.</ref>
 +
**First line is [[amoxicillin-clavulanate]] for 5-7 days
 +
**Second line is [[fluoroquinolone]] or [[doxycycline]]
  
<br/>> 10 days or if pt gets better and then worse again (“double sickening”)
+
===Antibiotic Failure===
 +
*Obtain culture
 +
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
 +
*Consider foreign body
 +
*Consider fungal treatment
  
*Mild bacterial sinusitis when pain is mild and temperature < 38.3˚C
+
==Disposition==
*Another seven days of observation
+
*Discharge
*Severe bacterial sinusitis when pain is moderate-severe or temperature ≥38.3˚C
 
*Consider antibiotics
 
*If the patient is immunocompromised, has an underlying or complicating condition, or patient fails observation, antibiotics are indicated
 
  
===Antibiotics===
+
==Complications==
 +
*[[Meningitis]]
 +
*[[Cavernous sinus thrombosis]] (ethmoid/sphenoid)
 +
*[[Intracranial abscess]]
 +
*[[Orbital cellulitis]] (ethmoid)
 +
*[[Frontal bone osteomyelitis]] (Pott's puffy tumor)
 +
*Extradural or subdural empyema
  
*Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
+
==See Also==
*Amoxicillin (500mg PO TID for 10 days)
+
*[[Headache]]
*TMP-SMX
 
*Erythromycin
 
*Azithromycin
 
*Cefpodoxime
 
* Cefdinir * Cefuroxime
 

 
*If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone
 
*Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation) and often is associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
 
  
 +
==References==
 +
<references/>
  
 
+
[[Category:ID]]
*Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis
 
 
 
 
 
 
 
== Source ==
 
 
 
DeBonis, Kaji, UpToDate "Rhinosinusitis"
 
 
 
<br/>[[Category:ID]]
 

Revision as of 13:30, 23 November 2017

Background

  • Viral source is by far most common. Bacterial infection accounts for only 0.5-2% of all cases[1]
    • Other causes include allergies and fungal infection
  • Timeframe
    • Acute (<4 weeks)
    • Subacute (4-12 weeks)
    • Chronic (>12 weeks)

Clinical Features

  • Defined as 2 or more of the following:
    • Blockage or congestion of nose
    • Facial pain or pressure
    • Hyposmia (diminished ability to smell)
    • Anterior or posterior nasal discharge lasting <12wk
  • Additional symptoms:
    • Tooth pain
    • Fever
    • Sinus pressure while bending forward to changing head position

Differential Diagnosis

Rhinorrhea

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

  • Clinical diagnosis
  • Consider CT only for toxic patients (to rule-out complication)

IDSA Guidelines 2012[2]

  • Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
  • Concern for bacterial (treat with antibiotics) if any of these:
    • Purulent discharge and pain on face or teeth > 10 days without improvement
    • Severe symptoms or fever > 39 plus symptoms > 3 days
    • "Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days

Management

<10 days of symptoms

>10 days of symptoms

  • Possible bacterial source, especially if associated with:
    • No clinical improvement after 10 days
    • Severe symptoms or high fever and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness
    • Onset with newly worsening that were initially improving (‘‘doublesickening’’)
  • Acute bacterial sinusitis[4]

Antibiotic Failure

  • Obtain culture
  • Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
  • Consider foreign body
  • Consider fungal treatment

Disposition

  • Discharge

Complications

See Also

References

  1. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar;(23):3 p preceding table of contents, 1-298
  2. Chow AW et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Disease (2012) 54:e72-112.
  3. Trestioreanu AZ, Yaphe J. "Intranasal steroids for acute sinusitis." The Cochrane Database of Systematic Reviews. 2 December 2013. DOI: 10.1002/14651858.CD005149.pub4
  4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. IDSA Guidelines. 2012; Clinical Infectious Diseases e1-e41.