RHINOSINUSITIS

Seminar presentation:
By:Dr.Vijay Mohan
DNB Resident-Family Medicine

INTRODUCTION

Sinusitis is one of the most common conditions treated by primary care

physicians. Each year in the United States, sinusitis affects one in seven
adults, and is diagnosed in 31 million patients.
The direct costs of sinusitis, including medications, outpatient and
emergency department visits, and ancillary tests and procedures, are
estimated to be $3 billion per year in the United States.
Sinusitis is the fifth most common diagnosis for which antibiotics are
prescribed.
Inflammation of the sinuses rarely occurs without concurrent inflammation
of the nasal mucosa; therefore, rhinosinusitis is a more accurate term for
what is commonly called sinusitis.
The American Academy of OtolaryngologyHead and Neck Surgery
defines subtypes of rhinosinusitis based on the duration of symptoms:
acute, subacute, recurrent acute, and chronic . Acute rhinosinusitis is
further categorized as bacterial or viral.

DEFINITION
The European Position Paper on rhinosinusitis and nasal polyps (EPOS 2012)3
presents an evidence-based approach to the treatment of all types of rhinosinusitis.
A definition of ARS in adults for use in primary care is:
Sudden onset of two or more symptoms,one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
+/ facial pain/pressure
+/ reduction or loss of smell
for <12 weeks;
with symptom free intervals if the problem is recurrent, with validation by
telephone or interview.
ARS becomes chronic rhinosinusitis (CRS) when symptoms persist for more
than 3 months.

ARS in children is defined as:

Sudden onset of two or more of the symptoms:
1. nasal blockage/obstruction/congestion
2. or discoloured nasal discharge
3. or cough (day and night time)

ETIOPATHOGENESIS

Most cases of acute rhinosinusitis are caused by viral infections

associated with the common cold. Mucosal edema leads to obstruction
of the sinus ostia.
In addition, viral and bacterial infections impair the cilia, which transport
mucus.
The maxillary sinuses, anterior ethmoid sinuses, and frontal sinuses all
drain through small ostia that converge into a small channel called the
ostiomeatal unit, which then empties into the middle meatus, beneath
the middle turbinate .
Obstruction at the ostiomeatal unit leads to obstruction of these sinuses
and secondary infection. The posterior ethmoid sinuses and sphenoid
sinuses are usually affected later.
The obstruction and slowed mucus transport cause stagnation of
secretions and lowered oxygen tension within the sinuses. This
environment is an excellent culture medium for viruses and bacteria.

ORGANISMS CAUSING SINUSITIS

.
o

Sinusitis most often follows a viral URI or an episode of allergic rhinitis.

Less frequently, sinusitis can result from direct bacterial contamination
from an infected tooth or trauma.
The most common bacterial organisms in community-acquired acute
bacterial rhinosinusitis are Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus, and Moraxella catarrhalis.
The most common viruses in acute viral rhinosinusitis are rhinovirus,
adenovirus, influenza virus, and parainfluenza virus.
Chronic sinusitis is caused by the same bacteria as in acute sinusitis,
but anaerobic bacteria, Pseudomonas spp., and staphylococci become
involved more often. The incidence of antibiotic resistant bacteria,
including MRSA and multidrug-resistant Pneumococcus, seems to be
increasing. Polymicrobial infections are not uncommon.
Sinusitis can also be caused by fungi. Invasive fungal sinusitis (caused
most often by Aspergillus or Mucor spp.) can be seen in patients with
impaired immune function and poorly controlled diabetes. It is life
threatening even with aggressive medical and surgical treatment

Much more common is a more indolent fungally mediated sinusitis.

Allergic fungal sinusitis is seen in patients with normal immune function.
This is often seen in association with nasal polyps and is thought to be
the result of an aberrant immune response to the fungus rather than a
true infection.
Patients do not always have type I hypersensitivity to fungi. Secondary
bacterialinfection is often associated with this problem.
Rarer causes of sinusitis are secondary to mycobacterial or parasitic
infection.

RISK FACTORS
The most important risk factor for the development of sinusitis is rhinitis (e.g.,
viral, allergic).
Other risk factors include

anatomic abnormalities (abnormality within the sinuses, septal deviation,

choanal atresia, foreign body, adenoid hypertrophy),&

nasal polyps (which can also occur secondary to chronic sinusitis),block the
opening of sinuses
conditions of local or systemic immunodeficiency,
cystic fibrosis,

primary ciliary dysfunction(Kartageners syndrome),

secondary ciliary dysfunction(cigarette smoking, nasal decongestant abuse,
cocaine abuse),

gastroesophageal reflux disease (GERD),

Systemic inflammatory conditions (sarcoidosis, Wegeners granulomatosis),
dental disease, and nasal or sinus tumors.
Any of these conditions can mimic or cause rhinosinusitis

SIGNS & SYMPTOMS

The signs and symptoms of sinusitis are divided into major and minor.

Major signs and symptoms include facial pain and pressure, nasal
congestion and obstruction, nasal discharge, discolored posterior
discharge, anosmia or hyposmia, fever (acute only),and purulence on
intranasal examination.
Minor signs and symptoms include headache, otalgia or ear pressure,
halitosis,dental pain, cough, fever (nonacute), and in children,fatigue
and irritability.

The diagnosis of sinusitis is probable if

the patient has two or more major factors

or one major andtwo or more minor factors.

A suggestive history is indicated by
the presence of one major factor or two minor factors

DIFFERENTIATING BACTERIAL FROM A

VIRAL ETIOLOGY

The signs and symptoms of acute bacterial rhinosinusitis and prolonged

viral upper respiratory infection are similar, which can lead to
overdiagnosis of acute bacterial rhinosinusitis.
The presence of purulent nasal drainage is not the sole criterion to
distinguish between viral and bacterial infection; the pattern and duration
of illness are also key.
In most patients, viral rhinosinusitis improves in seven to 10 days.
Diagnosis of acute bacterial rhinosinusitis requires that symptoms
persist for longer than 10 days or worsen after five to seven days.
Bacterial culture of secretions through meatal aspiration may be used
when resistant pathogens are suspected or if the patient is
immunocompromised.

COMPLICATIONS

The proximity of the paranasal sinuses to the orbits and brain potentially
allows infection to spread to these locations. Orbital and CNS
involvement of sinusitis can lead to loss of vision and can be life
threatening and therefore requires early recognition and treatment.
A high degree of clinical suspicion is required in cases of possible
complicated sinusitis, especially in young children. Patients with a recent
URI who present with periorbital erythema, vision change, increasing or
severe headache, high fever, oraltered mental status require urgent
evaluation and treatment. Periorbital and orbital cellulitis and CNS
complications require high dose IV antibiotics and surgical drainage.

Sphenoid and frontal sinusitis deserve special mention. In some cases,

drainage of the frontal sinuses is compromised. Chronic and recurrent
frontal sinusitis can lead to both intracranial and ophthalmologic
complications if untreated.
Large mucoceles,or mucopyeloceles can also form within the frontal
sinus, causing disfigurement and diplopia. These conditions usually
require surgical drainage.
Similarly, sphenoid sinusitis can rarely be aggressive. The carotid artery
and optic nerves traverse the lateral walls of the sphenoid sinuses. The
sphenoid sinus occupies a space inferior and anterior to the cranial
vault.
Acute or long-standing sphenoid sinusitis can progress to CNS or eye
complications, or both.

IMAGING

Radiographic imaging is not recommended for evaluating uncomplicated

acute rhinosinusitis.
Plain sinus radiography cannot be used to distinguish between bacterial
and viral etiologies; air-fluid levels are visible in patients with viral or
bacterial rhinosinusitis.
Sinus computed tomography should not be used for routine evaluation
of acute bacterial rhinosinusitis, but it can define anatomic abnormalities
and identify suspected complications.
Magnetic resonance imaging can be used to identify suspected tumors
or fungal sinusitis, which may involve adjacent soft tissue structures.

TREATMENT

Antibiotics may be considered in patients with symptoms or signs of

acute rhinosinusitis that do not improve within seven days or that worsen
at any time; in those with moderate to severe pain or a temperature of
101F (38.3C) or higher; and in those who are immunocompromised.
The challenge to the clinician in evaluating the patient with possible
sinusitis is to differentiate viral URI, allergic rhinitis, and even a migraine
headache, which do not require antibiotics, from bacterial sinusitis,
which does respond to antibiotic treatment.
Antibiotics should not be prescribed unless a bacterial infection is
certain or at least probable. The patient should be educated about the
rationale for this and usually responds favorably.

Goals of Medical Therapy

for Acute Sinusitis

Control Infection
Facilitate sinus ostial patency and drainage
Provide relief of symptoms
Evaluate and treat any predisposing
conditions to prevent recurrences

General Treatment for

Acute Sinusitis
Oral antibiotic
Topical and systemic
decongestants(Patients with poorly controlled hypertension or
coronary artery disease may not tolerate decongestants)

Pain medications
Optional or secondary
medications:
Guaifenesin(mucolytic) (1200 mg po
q 12h)
warm nasal saline irrigations qid
Antihistamine orally : only in the

Medication Interactions
in Rx of Acute Sinusitis
Remember that ciprofloxacin and
clarithromycin are contraindicated if
any of the nonsedating
antihistamines (terfenadine,
astemizole, and loratidine) are used
as they cause prolonged QT
syndrome and ventricular
arrhythmias
Also oral decongestants may cause
problems in patients on TCA's, MAO
inhibitors, and alpha blockers

Antibiotic Therapy
for Acute Sinusitis

According to Cochrane Collaboration recommendations for treatment of

acute sinusitis, antibiotics provide a minor improvement in simple, acute
(uncomplicated) sinus infections.However, 8 of 10 patients improve
without antibiotics within 2 weeks. The small benefit gained may be
overridden by the negative effects of antibiotics, both on the patient and
on the population in general.
For acute sinusitis confirmed by radiology or nasal endoscopy, current
evidence is limited but supports the use of intranasal steroids for acute
sinusitis as a monotherapy or as an adjuvant therapy to antibiotics.
Clinicians should weigh the modest but clinically important benefits
against possible minor adverse events when prescribing therapy.

Antibiotic selection in Adults

Selection of an antibiotic should be based on severity of symptoms, whether the

patient has received an antibiotic in the last 4 to 6 weeks, and the response to
current antibiotic therapy after 72 hours. Mild symptoms include rhinorrhea and
fatigue. Moderate symptoms include congestion, low-grade fever, and facial pain.

Antibiotic choices for adults with mild disease and no recent antibiotics include
amoxicillin (1.75-4 g/day, with or without clavulanate), cefpodoxime proxetil,
cefuroxime axetil, or cefdinir. TMP-SMX, doxycycline, azithromycin, erythromycin,
and clarithromycin may be considered in PCN-allergic patients, but the failure
rate may be as high as 20% to 25%. Failure of therapy should prompt
reevaluation of the patient or a switch in therapy.

Antibiotic choices for adults with moderate disease or with mild disease who
have received recent antibiotics include amoxicillin-clavulanate (4 g/day) or a
respiratory fluoroquinolone (levofloxacin or moxifloxacin).Ceftriaxone (1-2 g
parenterally for 5 days) or combination therapy for gram-positive and gramnegative bacteria may also be considered. Failure of therapy should prompt
reevaluation of the patient, CT scan, endoscopy with culture, or a switch in
therapy.

Antibiotic selection in Children

Antibiotic choices for children with mild disease and no recent antibiotics
include amoxicillin (90 mg/kg/day, with or without clavulanate), cefpodoxime
proxetil, cefuroxime axetil, or cefdinir. TMP-SMX, doxycycline, azithromycin,
erythromycin, and clarithromycin may be considered in PCN-allergic patients
(especially immediate type I hypersensitivity), but the failure rate may be as high
as 20 to 25%. Failure of therapy should prompt reevaluation of the patient or a
switch in therapy.
Antibiotic choices for children with moderate disease or with mild disease
who recently received antibiotics include amoxicillin-clavulanate (90 mg/kg/day).
Cefpodoxime proxetil, cefuroxime axetil, or cefdinir may be used if there is a
nonsevere PCN allergy (rash).Cefdinir is preferred because of high patient
acceptance.Ceftriaxone (50 mg/kg/day parenterally for 5 days) or combination
therapy for gram-positive and gram-negative bacteria may also be considered.
Failure of therapy should prompt reevaluation of the patient, CT scan,endoscopy
with culture, or a switch in therapy.
As recurrence or severity of the infection increases, broaderspectrum antibiotics
are indicated. Macrolides, fluoroquinolones, augmented penicillins, and
cephalosporins are useful in these cases. Culture-directed antibiotic treatment
maybe indicated in more refractory cases. Cultures can be obtained from an
endoscopically guided middle meatus swab/Maxillarysinus aspiration.

General Contributors to Chronic Sinusitis

Resistant infectious organisms

Underlying systemic illness (esp.
diabetes)
Immunodeficiency
Irreversible mucosal changes
Anatomic abnormality

Chronic Sinusitis

Medical treatment of chronic sinusitis is based on the same principles as for

acute sinusitis: improvement of mucociliary function and eradication of bacteria. If
chronic sinusitis is suspected, CT scan of the paranasal sinus should be ordered
to confirm the diagnosis before further treatment is initiated; treatment of chronic
sinusitis requires more aggressive therapy,with potential side effects. This
contrasts with acute sinusitis,for which CT is not necessary before treatment.

In addition to confirming the diagnosis and severity of the infections, CT can

identify abnormalities that can predict a poorer response to medical treatment.
This includes a posterior septal deviation, polyps, allergic fungal sinusitis, and
various sinus abnormalities.The scan may also arouse suspicion of sinonasal
mass or tumor.

Topical and systemic steroids can be used to improve drainage in cases of

chronic sinusitis by decreasing mucosal inflammation, edema, and mucus
production.
Most topical nasal steroids must be used daily for several weeks to have
significant benefit. Although oral steroids significantly improve symptoms, the
effects may be short-lived,and the potential side effects must be considered.
The efficacy of antibiotics in treating chronic sinusitis has not been validated in
controlled studies in adults. Two consensus statements do report that antibiotic
treatment is likely beneficial in adults but not in children.
Because of the apparent benefit, antibiotics are typically used to treat chronic
sinusitis in adults. An antibiotic with activity against staphylococci, as well as the
more typical pathogens (with predicted antibiotic resistance),must be chosen. In
cases of nasal polyps, an antibiotic withantipseudomonal activity may be
necessary.
Obtaining a middle meatal culture is extremely helpful in choosing an
appropriate antibiotic. Treating chronic sinusitis requires a longer course of
antibiotic treatment, often 3 to 8 weeks.
Surgical Management : if refractory to medical therapy or having underlying
abnormality : FESS

Fungal Sinusitis
Increasing incidence in both immunocompetent and
immunocompromised patients
3 types
Fulminant infection with soft tissue invasion
Progressive indolent invasive disease
Noninvasive localized disease ( mycetoma or allergic
fungal sinusitis)

 Causative fungi:
Aspergillus (most common)
Rhizopus (mucormycosis)
Candida
Histoplasma
Blastomces
Coccidioides
Cryptococcus

Presentation of Invasive or Acute

Fulminant Fungal Sinusitis

Facial soft tissue tenderness

Cloudy rhinorrhea
Fever
Gray, friable, anesthetic nasal tissue
May have necrotic black tissue
May have bloody rhinorrhea

Treatment of Invasive Fungal

Sinusitis

Always should be admitted

Correct metabolic abnomalities
High dose Amphotencin B +/fluconazole
Surgical debidement

Acute Sinusitis
Radiography
Plain films not as sensitive as CT
Radiographic signs of sinus pathology :
Air fluid levels
Partial or complete opacification
Bony wall displacement
4 mm or more of mucosal wall thickening
Single Water's view has high concordance with 4
view sinus series (Caldwell, Water's, lateral, &
submental vertex views)

Use of Computed Tomography (CT) for

Diagnosis of Sinusitis

Advantages of CT :
Visualizes ethmoid air cells
Evaluates cause of opacified sinus
Differentiates bony changes of
chronic inflammation from
osteomyelitis

Indicated only if complications

suspected or if diagnosis
uncertain

THANK YOU