Sinusitis: Difference between revisions

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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 (&lt;4 weeks)  
==Clinical Features==
##Acute viral
*Defined as 2 or more of the following:
##Acute bacterial (0.5-2% of cases)  
**Blockage or congestion of nose
#Subacute (4-12 weeks)
**Facial pain or pressure
#Chronic (&gt;12 weeks)  
**Hyposmia (diminished ability to smell)
#Other causes
**Anterior or posterior nasal discharge lasting <12wk
##Fungal infections
*Additional symptoms:
##Allergies
**Tooth pain
**[[Fever]]
**Sinus pressure while bending forward to changing head position
 
===Clinical Features of Bacterial Sinusitis===
*Symptoms persist >10 days
*Daytime [[cough]]
*Worsening or bimodal course
*Fever >102.2F (39C)
*Purulent nasal discharge >3d
*Pain in maxillary teeth
*Hx of diabetes
 
==Differential Diagnosis==
{{Rhinorrhea}}
 
{{Headache DDX}}
 
==Evaluation==
*Clinical diagnosis
*Consider CT only for toxic patients (to rule-out complication)
 
===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


==Clinical Features==
==Management==
#Defined as 2 or more of the following:
===<10 days of symptoms===
##Blockage or congestion of nose
*Symptomatic treatment:  
##Facial pain or pressure
**[[Analgesia]]
##Hyposmia (diminished ability to smell)
**Mechanical irrigation with buffered, hypertonic saline
##Anterior or posterior nasal discharge lasting <12wk
**OTC decongestants
#Additional symptoms:
**Intranasal decongestants (e.g. [[oxymetazoline]] for no more than 3 days)  
##Tooth pain
**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>
##Fever
*Avoid antibiotics (Part of [[Choosing wisely ACEP|ACEP Choosing wisely]])
##Sinus pressure while bending forward to changing head position


==Diagnosis==
===>10 days of symptoms===
#Consider CT only for toxic pts (to r/o complication)
*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<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>
**Strep pneumo, non-typeable H. flu, Moraxella
**First line is [[amoxicillin-clavulanate]] for 7-10 days
***Amox 40-45mg/kg PO with clavulanate 3.2 mg/kg PO bid for 10d
**Second line is [[fluoroquinolone]] or [[doxycycline]]
**If allergic, can use [[cefdinir]] (7mg/kg PO bid) or [[cefuroxime]] (15 mg/kg PO bid)


==DDX==
===Antibiotic Failure===
#Migraine
*Obtain culture
#Craniofacial neoplasm
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
#Foreign body retention
*Consider [[foreign body]]
#Dental caries
*Consider [[antifungals]]


== Treatment  ==
==Disposition==
#<10 days of symptoms
*Discharge
##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 3d)
###Antihistamines
###Mucolytics
#>10 days of symptoms 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 amoxicillin
###Consider fluoroquinolone or amoxicillin-clavulanate if pt has had abx in past 4-6wks
#Antibiotic Failure
##Obtain culture
##Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
##Consider foreign body
##Consider fungal treatment


==Complications==
==Complications==
#Meningitis
*[[Meningitis]]
#Cavernous sinus thrombosis (ethmoid/sphenoid)
*[[Cavernous sinus thrombosis]] (ethmoid/sphenoid)
#Intracranial abscess
*[[Intracranial abscess]]
#Orbital cellulitis (ethmoid)
*[[Orbital cellulitis]] (ethmoid)
#Frontal bone osteomyelitis (Pott's puffy tumor)
*[[Frontal bone osteomyelitis]] (Pott's puffy tumor)
#Extradural or subdural empyema
*Extradural or subdural empyema
 
==See Also==
*[[Headache]]


== Source ==
==References==
*UpToDate
<references/>
*Tintinalli


[[Category:ID]]
[[Category:ID]]

Revision as of 04:06, 24 September 2019

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

Clinical Features of Bacterial Sinusitis

  • Symptoms persist >10 days
  • Daytime cough
  • Worsening or bimodal course
  • Fever >102.2F (39C)
  • Purulent nasal discharge >3d
  • Pain in maxillary teeth
  • Hx of diabetes

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 antifungals

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.