Difference between revisions of "Sinusitis"

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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>
*Acute (&lt;4 weeks)
+
**Other causes include allergies and fungal infection
**Acute viral
+
*Timeframe
**Acute bacterial (0.5-2% of cases)<ref>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>
+
**Acute (<4 weeks)
*Subacute (4-12 weeks)  
+
**Subacute (4-12 weeks)  
*Chronic (>12 weeks)  
+
**Chronic (>12 weeks)  
*Other causes
 
**Fungal infections
 
**Allergies
 
  
 
==Clinical Features==
 
==Clinical Features==
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**Fever
 
**Fever
 
**Sinus pressure while bending forward to changing head position
 
**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==
 
==Differential Diagnosis==
*[[Migraine]]
+
{{Rhinorrhea}}
*Craniofacial neoplasm
+
 
*[[Foreign body]] retention
+
{{Headache DDX}}
*Dental caries
 
  
 
==Evaluation==
 
==Evaluation==
 +
*Clinical diagnosis
 
*Consider CT only for toxic patients (to rule-out complication)
 
*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
  
 
==Management==
 
==Management==
 
===<10 days of symptoms===
 
===<10 days of symptoms===
*Symptomatic treatment b/c most likely viral
+
*Symptomatic treatment:
 
**Analgesia  
 
**Analgesia  
 
**Mechanical irrigation with buffered, hypertonic saline  
 
**Mechanical irrigation with buffered, hypertonic saline  
**Topical glucocorticoids - Flonase
+
**OTC decongestants
**Dexamethasone 10mg PO x1 dose
+
**Intranasal decongestants (e.g. [[oxymetazoline]] for no more than 3 days)  
**Zicam
+
**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>
**Topical decongestants (e.g. [[oxymetazoline]] for no more than 3d)  
+
*Avoid antibiotics (Part of [[Choosing wisely ACEP|ACEP Choosing wisely]])
**[[Antihistamines]]  
 
**Mucolytics
 
*Avoid antibiotics
 
**Part of [[Choosing wisely ACEP|ACEP Choosing wisely ]]
 
  
 
===>10 days of symptoms===
 
===>10 days of symptoms===
*Suspicious for bacterial origin especially with:
+
*Possible bacterial source, especially if associated with:
 
**No clinical improvement after 10 days
 
**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
 
**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’’)
 
**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>
 
*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]] (over [[amoxicillin]] alone) for 5-7 days, not 10-14
+
**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]]
 
**Second line is [[fluoroquinolone]] or [[doxycycline]]
 
+
**If allergic, can use cefdinir (7mg/kg PO bid) or cefuroxime (15 mg/kg PO bid)
===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
 
*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
 
  
 
===Antibiotic Failure===
 
===Antibiotic Failure===
 
*Obtain culture
 
*Obtain culture
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
+
*Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal intubation)
 
*Consider foreign body
 
*Consider foreign body
 
*Consider fungal treatment
 
*Consider fungal treatment
  
 
==Disposition==
 
==Disposition==
*Typically outpatient
+
*Discharge
  
 
==Complications==
 
==Complications==
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==See Also==
 
==See Also==
 +
*[[Headache]]
  
 
==References==
 
==References==

Latest revision as of 13:53, 23 June 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]
    • 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)

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.