Acute and Chronic Sinusitis - A Practical Guide for Diagnosis and Treatment docx

Be knowledgeable of the causes of and risk factors associated with sinusitis Differentiate acute from chronic sinusitis Evaluate patients by history, physical exam, appropriate laborato

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This is a presentation of the

American Academy of Family Physicians supported by an educational grant from

Aventis Pharmaceuticals

The AAFP gratefully acknowledges

Harold H Hedges, III, M.D

and Susan M Pollart, M.D

for developing the content for the AAFP

and Harold H Hedges, HI, M.D for providing the photo images included in this slide presentation

Acknowledgments

Harold H Hedges, III, M.D

Private Practice

Little Rock Family Practice Clinic

Little Rock, Arkansas

Be knowledgeable of the causes of and risk factors associated with sinusitis

Differentiate acute from chronic sinusitis

Evaluate patients by history, physical exam, appropriate laboratory and imaging studies, and when indicated screen patients for allergy

Prescribe appropriate medication regimens for acute and chronic sinusitis

Know of the relationships between upper airway (rhinosinusitis) and lower airway disease (asthma)

Allergic or nonallergic rhinitis nearly always precedes sinusitis

Sinusitis without rhinitis 1s rare

Nasal discharge and congestion are prominent symptoms of sinusitis

Nasal mucosa and sinus mucosa are similar and are contiguous

scope of Sinusitis

Affects 30-35 million persons/year

25 million office visits/year

Direct annual cost $2.4 billion and increasing Added surgical costs: $1 billion

Third most common diagnosis for which antibiotics are prescribed

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Normal Sinus

¢ Sinus health depends on:

— Mucous secretion of normal viscosity, volume, and

composition,

— normal mucociliary flow to prevent mucous stasis and subsequent infection;

— and open sinus ostia to allow adequate drainage and aeration

¢ Senior BA, Kennedy DW Management of sinusitis 1n the

asthmatic patient AAAT J,1996;77:6-19

Development of Sinuses

¢ Maxillary and ethmoid sinuses present at birth

¢ Frontal sinus developed by age 5 or 6

¢ Sphenoid sinus last to develop, 8-10

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Physiologic Importance of Sinuses

Provide mucus to upper airways

— Lubrication

— Vehicle for trapping viruses, bacteria, foreign material for removal

Give characteristics to voice

Lessen skull weight

Involved with olfaction

Sinusitis

Infectious or noninfectious inflammation of 1 or more sinuses

¢ 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells

Frontal

Maxillary Ethmoid Sphenoid

Lateral View Showing Normal

Sphenoid Sinus

Ostiomeatal Complex

¢ QOstiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and

maxillary sinuses drain

¢ Posterior ethmoids drain into the upper meatus

¢ Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)

Subacute bacterial sinusitis- infection lasting between 4 to

12 weeks, yet resolves completely (children 30-90 days)

Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)

Some guidelines add treatment failure + a positive imaging

Recurrent Acute Bacterial Sinusitis

¢ Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic

¢ 3 episodes in 6 months or 4/year

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Acute Sinusitis Imposed on

Chronic Sinusitis

Patients with chronic, low grade symptoms experience increase in mucous flow, change in viscosity or color, or secretions

Treated

New symptoms resolve but chronic symptoms continue

Nasal congestion Purulent rhinorrhea Postnasal drip

Headache Facial pain Anosmia Cough, fever

Nasal congestion Rhinorrhea clear

Runny nose

Itching, red eyes

Nasal crease

Seasonal symptoms

Road to Bacterial Sinus Infections

Obstruction of the various ostia Impairment in ciliary function Increased viscosity of secretions Impaired immunity

Mucus accumulates Decrease in oxygenation in the sinuses Bacterial overgrowth

Pathogenesis of Nasal Obstruction

Viral upper respiratory infections

Allergic Stimuli Causing Rhinosinusitis

Pollens

— Tree, grass, weeds

House dust mite

Car exhaust, diesel fumes

Hair spray

Cold aIr Dry air

Changes in barometric pressure

Auto exhaust

Gas, diesel fuel

Nonallergic foods Nonallergic beverages

Causes of Ciliary Dysfunction

Immotile cilia syndrome Prolonged exposure to cigarette smoke Common cold viruses causing URI

Increased viscosity of mucus

Medications

— First generation antihistamines (non sedating do not affect) Anticholinergics

Asprrin Anesthetic agents

@,, ~ Benzodiazepines

Diseases Slowing Ciliary Function

Allergic and nonallergic rhinitis Rhinosinusitis

Aging rhinitis Cystic fibrosis Any disease causing obstruction, crusting of the mucosa

Causes of Mechanical Obstruction

Deviated nasal septum Concha bullosa

Foreign body Nasal polyps Congenital atresia Lymphoid hyperplasia Nasal structural changes found in Downs syndrome

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Vasculitides, Autoimmune and

Granulomatous Diseases

Churg-Strauss vasculitis Systemic lupus erythematosis Sjogren’s syndrome

Sarcoidosis Wegener granulomatosis

Other Predisposing Conditions

Physical trauma Scuba diving Foreign body Cleft palate Dental disorders

Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis

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Usually begins with viral upper respiratory illness Symptoms initially improve, but then

Symptoms become persistent or severe

Persistent 10-14 days but fewer than 4 weeks

Severe temperature of 102°, purulent nasal discharge for 3-4 days, child appears 11

Disease clears with appropriate medical treatment

Mucopurulent nasal discharge

— Highest positive predictive value

Swelling of nasal mucosa Mild erythema

Facial pain (unusual in children) Periorbital swelling

Physical Findings

Objectives of Treatment of Acute

Treatment of Acute Sinusitis

Antihistamines recommended if allergy present

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Decongestants

¢ Topical nasal sprays (limit use to 3-7 days)

— Phenylephrine Oxymetazoline Naphthazoline Tetrahydrozoline Zylometazoline

¢ Topical nasal spray (unlimited daily use)

— Ipatropium

x1)

— Pseudoephedrine 30-60 mg

— Phenylephrine 2-4 times/day

Treatment of Acute,

Uncomplicated Sinusitis

¢ Antibiotic may not be indicated

— Many are viral

— Benefit of antibiotics are only moderate

— Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions

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Antibiotics for Acute Bacterial Sinusitis

¢ Amoxicillin 500 mg tid for 10-14 days

— First line choice in most areas

— Local differences in antibiotic resistance occur

¢ Where beta-lactanase resistance is an issue

— Amoxicillin/clavulanate

— Cefuroxime

— Cefpodoxime

— Cefprozil

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Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to I4 days)

If penicillin-allergic clarithromycin or azithromycin Erythromycin does not provide adequate coverage Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

Commercial buffered sprays Bulb syringe

— 1/4 tsp of salt to 7 ounces water

Waterpik with lavage tip

— | tsp salt to reservoir

Disposable enema bucket

— 2 tsp salt, 1 tsp soda per quart of water

Nasal Irrigation

Nasal Irrigation

Washes away irritants Moistens the dry nose Waterpik with nasal irrigator Ceramic irrigators

Enema bucket with normal saline and soda

— “Hose-in-the-nose’’ $2.50

Nasal Irrigation

— Add 2 teaspoons of salt and | tsp of baking soda to a quart of

Wwarm wafer

— Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2

solution Turn head to opposite side and repeat process

Use once, twice daily or as often as needed

Assess for chronic causes

Identify allergic and nonallergic triggers Allergy testing, nasal smears for eosinophilia

Consider other medical conditions associated with sinusitis

Rhinolaryngoscopy Imaging studies Sinus x-rays

CT scanning (limited, coronal views)

Sinus Transillumination

Helpful in older children and adults

Normal transillumination decreases chance of pus in the

Have patient sit at your eye level in darkened room (the darker the better)

Let eyes get accustomed to dark

Place bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses

Look at palate for presence/absence of transilluminated

Proguarg Qualty CM

Proguatg Quality COMI

Proguarg Quality OMT

Rhinoscopy Aids in Diagnosing

Nasal polyps Septal devIation Concha bullosa Eustachian tube dysfunction Causes of hoarseness

Adenoid hyperplasia

Tumors

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MRI Imaging

¢ Not used for imaging suspected acute sinusitis

¢ Suspected fungal sinusitis

¢ Suspected tumors

Bacteria Involved in Acute

Bacterial Sinusitis

Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis

Sterile

* Presumed; no data on individual symptoms Nayak AS, et al Ann Allergy Asthma Immunol 2002;88:592-600

++++ = Strongly positive effect; += Minimal effect

Rational for Starting Rx with Amoxicillin

In the absence of risk factors, 1.e attendance in daycare center, recent antibiotics, age younger than 2

80% of patients will respond to amoxicillin

Give Rx for 5 days with a refill 1f responding treat for 10

to 14 days, if not, switch to another

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Reasons to Use Alternative Antibiotics

No response to amoxicillin within 3-5 days Recent treatment with amoxicillin for other causes Symptoms present for more than 30 days

Recurrent sinus infections

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secondary Antibiotics for Acute Sinusitis

Cefdinir (Omnicef) Cefuroxime (Ceftin) Cephpodoxime (Vantin) Azithromycin

Clarithromycin

Optimal Duration of Antibiotics

Give antibiotic until patient free of symptoms then add 7 days

Chronic Sinusitis

Symptoms present longer than 8 weeks or 4/year in adults

or 12 weeks or 6 episodes/year in children Eosinophilic inflammation or chronic infection Associated with positive CT scans

Poor (if any) response to antibiotics

Fatigue Concentration Nuisance

Sleep disturbance Emotional well being

Decreased production Impaired studying

Sniffing/snorting Blowing nose

Sx of Chronic Sinusitis

Nasal discharge Nasal congestion Headache

Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down)

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Conditions Causing Chronic Sinusitis

Allergic and nonallergic rhinitis Uncorrected anatomic conditions Ciliary dyskinesia

Evaluation of Chronic Sinusitis

CT or MRI scanning

— Anatomic defects, tumors, fungi

Allergy testing

— Inhalants, fungi, foods

Sinus aspiration for cultures

— Bacterial

— Fungal

Immunoglobulins

Treatment of Chronic Sinusitis

Nasal steroid spray CGuafenesIn

Decongestants

Steam inhalation Nasal irrigation

Antibiotics with exacerbations

Bacteria Involved in Chronic Sinusitis

Role of Viruses is Unknown

Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus

Coagulase negative staphylococcus

Anerobic bacteria

In one study, while initial aspirates showed strep pneumoniae, H influenzae, and M catarrhalis, subsequent cultures showed Porphyromonas, Peptostreptococcus, and aerobic organisms found to be increasingly resistant to

sinus Aspiration and Culture

Recommendations Made for

Antibiotic Prophylaxis in ABS

¢ Has not been evaluated as has its use in otitis media

° Increasing evidence of antibiotic resistance is an issue

¢ May be tried in chronic or recurrent disease

The Sinusitis-Asthma Connection

Mechanism is not understood

Indications for Referral

¢ Allergy testing, possible immunotherapy

¢ Sinus aspiration for bacterial culture

¢ Surgical intervention

— Correct obstructive process

— Drain sinus abscesses

— Consideration to remove nasal polyps

Indications for Hospitalization

Acutely ill child or adult with high fever, severe head pain Suspected sphenoid sinusitis

Anytime complications of eye, bone or intracranial

structures are present

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The recommendations cited are those proposed by a task force of the American Academy of Pediatrics in

consultation with other groups regarding the evaluation, diagnosis, and treatment of patients aged 1-21 years with sinus disease expert opinion was used when insufficient data could be found

Recommendation 1

The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe

Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older

than age 6 years is controversial)

Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time

Children < 6 symptoms predicted 88% of the time Normal x-ray suggests ABS is not present

CT scans of the paranasal sinuses should be reserved for:

Patients in whom surgery is being considered as a