Sinusitis

Revision as of 07:44, 12 March 2011 by Rossdonaldson1 (talk | contribs) (Antibiotics)

Background

Rhinosinusitis - Inflammation of the lining of the paranasal sinuses

  1. Acute (< 4 weeks)
    1. Acute viral
    2. Acute bacterial (0.5-2% of cases)
  2. Subacute (4-12 weeks)
  3. Chronic (>12 weeks)
  4. Other causes
    1. Fungal infections
    2. Allergies

Diagonsis

Classic History & Physical

Feature
Viral
Bacterial

Duration (symptoms)

<10days
Usually >10 days OR worsening symptoms within 10 days after initial improvement

Color change (nasal discharge)

+/−
+++, quality usually yellow-green and thick

Maxillary dental pain

+++, often unilateral and associated with a particular sinus

Postnasal drip

More common

Fever, cough, fatigue

More common

Hyposmia/anosmia

More common

Treatment

  1. < 10 days symptomatic treatment b/c most likely viral
    1. Analgesia
    2. Mechanical irrigation with buffered, hypertonic saline
    3. Topical glucocorticoids
    4. Topical decongestants (e.g., oxymetazoline for no more than three days)
    5. Antihistamines
    6. Mucolytics
  2. 10 days or if pt gets better and then worse again (“double sickening”)
    1. Mild bacterial sinusitis when pain is mild and temperature < 38.3˚C
    2. Another seven days of observation
    3. Severe bacterial sinusitis when pain is moderate-severe or temperature ≥38.3˚C
    4. Consider antibiotics
    5. If the patient is immunocompromised, has an underlying or complicating condition, or patient fails observation, antibiotics are indicated

Antibiotics

  1. Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
    1. Amoxicillin (500mg PO TID for 10 days)
    2. TMP-SMX
    3. Erythromycin
    4. Azithromycin
    5. Cefpodoxime

##Cefdinir * Cefuroxime

Antibiotic Failure

#If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone

  1. 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
  2. Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis

Source

DeBonis, Kaji, UpToDate "Rhinosinusitis"