Difference between revisions of "Sinusitis"

(<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)
  
#Acute (<4 weeks)
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==Clinical Features==
##Acute viral
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*Defined as 2 or more of the following:
##Acute bacterial (0.5-2% of cases)
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**Blockage or congestion of nose
#Subacute (4-12 weeks)
+
**Facial pain or pressure
#Chronic (>12 weeks)
+
**Hyposmia (diminished ability to smell)
#Other causes
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**Anterior or posterior nasal discharge lasting <12wk
##Fungal infections
+
*Additional symptoms:
##Allergies
+
**Tooth pain
 +
**Fever
 +
**Sinus pressure while bending forward to changing head position
  
== Diagonsis ==
+
==Differential Diagnosis==
 +
{{Rhinorrhea}}
  
{| width="437" border="1"
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{{Headache DDX}}
|-
 
| style="width: 581px; height: 14px" colspan="3" width="437" valign="top" |
 
'''Classic History & Physical'''
 
  
|-
+
==Evaluation==
| style="width: 156px; height: 15px" width="117" | <center><br/></center>
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*Clinical diagnosis
| style="width: 87px; height: 15px" width="66" | <center>'''Viral'''</center>
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*Consider CT only for toxic patients (to rule-out complication)
| 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>
+
===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>===
| style="width: 338px; height: 15px" width="254" | <center>Usually >10 days OR worsening symptoms within 10 days after initial improvement</center>
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*Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
|-
+
*Concern for bacterial (treat with antibiotics) if any of these:
| style="width: 156px; height: 29px" width="117" |
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**Purulent discharge and pain on face or teeth > 10 days without improvement
Color change (nasal discharge)
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**Severe symptoms or fever > 39 plus symptoms > 3 days
 +
**"Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days
  
| style="width: 87px; height: 29px" rowspan="5" width="66" | <center>+/−</center>
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==Management==
| style="width: 338px; height: 29px" width="254" | <center>+++, quality usually yellow-green and thick</center>
+
===<10 days of symptoms===
|-
+
*Symptomatic treatment:  
| style="width: 156px; height: 14px" width="117" |
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**Analgesia
Maxillary dental pain
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**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]])
  
| style="width: 338px; height: 14px" width="254" | <center>+++, often unilateral and associated with a particular sinus</center>
+
===>10 days of symptoms===
|-
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*Possible bacterial source, especially if associated with:
| style="width: 156px; height: 14px" width="117" |
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**No clinical improvement after 10 days
Postnasal drip
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**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<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]]
  
| style="width: 338px; height: 14px" width="254" | <center>More common</center>
+
===Antibiotic Failure===
|-
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*Obtain culture
| style="width: 156px; height: 15px" width="117" |
+
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
Fever, cough, fatigue
+
*Consider foreign body
 +
*Consider fungal treatment
  
| style="width: 338px; height: 15px" width="254" | <center>More common</center>
+
==Disposition==
|-
+
*Discharge
| style="width: 156px; height: 14px" width="117" |
 
Hyposmia/anosmia
 
  
| style="width: 338px; height: 14px" width="254" | <center>More common</center>
+
==Complications==
|}
+
*[[Meningitis]]
 +
*[[Cavernous sinus thrombosis]] (ethmoid/sphenoid)
 +
*[[Intracranial abscess]]
 +
*[[Orbital cellulitis]] (ethmoid)
 +
*[[Frontal bone osteomyelitis]] (Pott's puffy tumor)
 +
*Extradural or subdural empyema
  
== Treatment ==
+
==See Also==
*1. <10 days
+
*[[Headache]]
**Symptomatic treatment b/c most likely viral
 
***Analgesia
 
***Mechanical irrigation with buffered, hypertonic saline
 
***Topical glucocorticoids
 
***Topical decongestants (e.g., oxymetazoline for no more than three days)
 
***Antihistamines
 
***Mucolytics
 
*2. >10 days or if pt gets better and then worse again (“double sickening”)
 
**Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
 
***Another seven days of observation
 
**Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
 
***Consider antibiotics
 
*If pt is immunocompromised, has underlying condition, or fails observation abx are indicated
 
*Obtain CT w/ contrast if concern for complications of sinusitis (e.g. postseptal cellulitis)
 
  
=== Antibiotics ===
+
==References==
#Choice depends on recent antibiotic therapy (past 4-6 weeks)
+
<references/>
##Amoxicillin 80mg/kg/d x 10-14d
 
##Azithromycin 10mg/kg PO on day 1; then 5mg/kg QD x 5-7d
 
##Cefpodoxime
 
##Cefdinir
 
##Cefuroxime
 
  
=== Antibiotic Failure ===
+
[[Category:ID]]
*If initial abx failure occurs consider further workup (e.g. CT) and/or further tx w/ amoxicillin-clavulanate or respiratory fluoroquinolone
 
*Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation)
 
**Associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
 
*Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis
 
 
 
==Source==
 
 
 
UpToDate
 
 
 
Tintinalli
 
 
 
[[Category:ID]] <br/>
 

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.