Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3) ppt

In acute sinusitis, sinus pain or pressure often localizes to the involved sinus particularly the maxillary sinus and can be worse when the patient bends... Although rare, manifestations

Chapter 031 Pharyngitis, Sinusitis, Otitis, and Other

Upper Respiratory Tract Infections

(Part 3)

Clinical Manifestations

Most cases of acute sinusitis present after or in conjunction with a viral URI, and it can be difficult to discriminate the clinical features of one from the other A large proportion of patients with colds have sinus inflammation, although bacterial sinusitis complicates only 0.2–2% of these viral infections Common presenting symptoms of sinusitis include nasal drainage and congestion, facial pain or pressure, and headache Thick, purulent or discolored nasal discharge is often thought to indicate bacterial sinusitis but also occurs early in viral infections such as the common cold and is not specific to bacterial infection Other nonspecific manifestations include cough, sneezing, and fever Tooth pain, most often involving the upper molars, is associated with bacterial sinusitis, as is halitosis

In acute sinusitis, sinus pain or pressure often localizes to the involved sinus (particularly the maxillary sinus) and can be worse when the patient bends

over or is supine Although rare, manifestations of advanced sphenoid or ethmoid sinus infection can be profound, including severe frontal or retroorbital pain radiating to the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitis Acute focal sinusitis is uncommon but should be considered in the patient with severe symptoms over the maxillary sinus and fever, regardless of illness duration Similarly, advanced frontal sinusitis can present with a condition

known as Pott's puffy tumor, with soft tissue swelling and pitting edema over the

frontal bone from a communicating subperiosteal abscess Life-threatening complications include meningitis, epidural abscess, and cerebral abscess

Patients with acute fungal sinusitis (such as mucormycosis) often present with symptoms related to pressure effects, particularly when the infection has spread to the orbits and cavernous sinus Signs such as orbital swelling and cellulitis, proptosis, ptosis, and decreased extraocular movement are common, as

is retroorbital or periorbital pain Nasopharyngeal ulcerations, epistaxis, and headaches are also frequent, and involvement of cranial nerves V and VII has been described in more advanced cases Bony erosion may be evident on examination Oftentimes, the patient does not appear seriously ill despite the rapidly progressive nature of these infections

Patients with acute nosocomial sinusitis are often critically ill and thus do not manifest the typical clinical features of sinus disease This diagnosis should be

suspected, however, when hospitalized patients who have appropriate risk factors (e.g., nasotracheal intubation) develop fever of unknown origin

Diagnosis

Distinguishing viral from bacterial sinusitis in the ambulatory setting is usually difficult, given the relatively low sensitivity and specificity of the common clinical features One clinical feature that has been used to help guide diagnostic and therapeutic decision-making is illness duration Because acute bacterial sinusitis is uncommon in patients whose symptoms have lasted <7 days, several authorities now recommend reserving this diagnosis for patients with "persistent" symptoms (i.e., symptoms lasting >7 days in adults or >10–14 days in children) accompanied by purulent nasal discharge (Table 31-1) Even among the patients who meet these criteria, only 40–50% have true bacterial sinusitis The use of CT

or sinus radiography is not recommended for routine cases, particularly early in the course of illness (i.e., at <7 days), given the high prevalence of similar abnormalities among cases of acute viral rhinosinusitis In the evaluation of persistent, recurrent, or chronic sinusitis, CT of the sinuses is the radiographic study of choice

Table 31-1 Guidelines for the Diagnosis and Treatment of Acute Sinusitis

Age

Group

Diagnostic Criteria

Treatment Recommendationsa

Moderate symptoms (e.g., nasal purulence/ congestion or

cough) for >7 d or

Initial therapy

Severe symptoms

of any duration, including unilateral/focal facial swelling or tooth pain

Amoxicillin, 500 mg PO tid or

875 mg PO bid, or

TMP-SMX, 1 DS tablet PO bid for 10–14 d

Adults

Exposure to antibiotics within 30

d or >30% prevalence of penicillin-resistant S pneumoniae

Amoxicillin, 1000 mg PO tid,

or

Amoxicillin/clavulanate

(extended release), 2000 mg PO bid, or

Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500

mg PO qd)

Recent treatment failure

Amoxicillin/clavulanate

(extended release), 2000 mg PO bid, or

Amoxicillin, 1500 mg bid, plus

clindamycin, 300 mg PO qid, or

Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500

mg PO qd)

Moderate symptoms (e.g., nasal

purulence/congestion or

cough) for >10–14 d or

Initial therapy

Severe symptoms

of any duration, including

fever (>102°F),

unilateral/focal facial

swelling or pain

Amoxicillin, 45–90 mg/kg qd (up to 2 g) PO in divided doses (bid or

tid), or

Cefuroxime axetil, 30 mg/kg

qd PO in divided doses (bid), or

Cefdinir, 14 mg/kg PO qd Children

Exposure to antibiotics within 30

d, recent treatment failure, or >30% prevalence of penicillin-resistant S

pneumoniae

Amoxicillin, 90 mg/kg qd (up

to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid) (extra-strength

suspension), or

Cefuroxime axetil, 30 mg/kg

qd PO in divided doses (bid), or

Cefdinir, 14 mg/kg PO qd

a

Unless otherwise specified, the duration of therapy is generally 10 d, with appropriate follow-up

Note: DS, double-strength; TMP-SMX, trimethoprim-sulfamethoxazole

Sources: American Academy of Pediatrics Subcommittee on Management

of Sinusitis and Committee on Quality Improvement, 2001; Hickner et al, 2001; Piccirillo, 2004; and Sinus and Allergy Health Partnership, 2004

The clinical history and/or setting can often identify cases of acute anaerobic bacterial sinusitis, acute fungal sinusitis, or sinusitis from noninfectious causes (e.g., allergic rhinosinusitis) In the case of an immunocompromised patient with acute fungal sinus infection, immediate examination by an otolaryngologist is required Biopsy specimens from involved areas should be examined by a pathologist for evidence of fungal hyphal elements and tissue invasion Cases of suspected acute nosocomial sinusitis should be confirmed by sinus CT Because therapy should target the offending organism, a sinus aspirate should be obtained,

if possible, for culture and susceptibility testing