Sinusitis CKS | A4Medicine

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Sinusitis CKS

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Sinus infection accounts for close to 16 million
office visits per year ( USA ). Sinusitis CKS is
more common from early fall to early spring. It
is much more common in adults than children.
approximately 0.5 of upper respiratory tract
infections are complicated by sinusitis. Acute
sinusitis is the second most common infectious
disease seen by GPs ( Acute sinusitis Can Fam
Physician 2011). This review covers acute
sinusitis presentation.Sinusitis is an
inflammation of the mucosal lining of the
paranasal sinuses .Inflammation of the sinus
cavities is almost always accompanied by
inflammation of the nasal cavities
RHINOSINUSITIS is a more suitable and preferred
termObstruction of sinus drainage pathways
Ciliary impairment Altered mucus quantity and
qualityCauses risk factors Viral infection-
most common cause and include? Respiratory
syncytial virus Rhinovirus Parainfluenza
Influenza with rhinovirus Acute bacterial
infection Following an episode of viral sinusitis
0.5 to 2 cases will progress to acute
bacterial sinusitis Sinusitis is one of the
commonest reasons a healthcare professional will
prescribe an antibioticMost commonly implicated
bacteria are Streptococcus pneumoniae Haemophilus
influenzae Allergic and non-allergic rhinitis
Anatomical variations abnormality of osteomeatal
complex septal deviation cleft palate concha
bullosa pneumatized ( air filled ) cavity
withih a turbinate in the nose ( Google )
hypertrophic middle turbinates Cigarette smoking
gt can damage cilia Asthma chronic sinusitis
and nasal polyps Diabetes risk chronic
sinusitis Swimming , diving , high altitude
climbing Dental infections and procedures
Diagnosed more frequently in women than men
Aspirin sensitivity.Cystic fibrosis Neoplasia
Mechanical ventilation Use of nasal tubes such as
NG feeding tubes Sarcoidosis Immunodeficiency
Wegeners granulomatosis Sinus surgery Immotile
cilia syndromePresentation- Most common cause of
acute sinusitis is a viral infection usually
follows a common cold Clinical findings may
include Pain over cheek radiating to frontal
region or teeth ?? with straining or bending down
Facial pain or pressure Headache Persistent cough
( ?? at night ) Tenderness pressure over the
floor of the frontal sinuses immediately above
inner canthus Nasal blockage ( obstruction /
congestion ) Disoloured nasal discharge ( ant /
post nasal drip ) Hyposmia reduced sense smell
ToothacheAcute Bacterial Sinusitis -ABRS-
Discoloured discharge ? unilateral predominance
purulent secretions in the nasal cavity Severe
local pain ( unilateral predominance )Fever gt
38Elevated ESR / CRP Double sickening a
deterioration after an initial milder phase of
illness. Caused by a virus in 98 cases takes
an average 2.5 weeks to resolve and antibiotics
only likely to help if features suggestive of
bacterial infectionExamination- Inspect and
palpate the maxillofacial area Check nasal
cavity- rhinoscopy for?? nasal inflammation??
mucosal oedema?? mucupurulent nasal discharge??
nasal polyps?? anatomical abnormalities eg
deviated nasal septum?? nasal foreign body??
sinonasal tumour

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Caution- Periorbital oedema / erythema Displaced
globe Double vision Ophthalmoplegia Reduced
visual acuity Severe frontal headache Swelling
over frontal bone Symptoms and signs of
meningitis Focal neurological signsManagement-
Paracetamol or NSAID Intranasal decongestant
Topical agents preferred over systemic Up to 3-5
days prevent rebound congestion eg
Oxymetazoline nasal spray Intranasal
corticosteroid patients with congestion low
systemic Ses advised min 1 month use Irrigating
nose with nasal saline solution Warm face packs
Adequate hydration Ipratropium if congested (
topical anticholinergic )Immunocompromised or
severe illness-High dose amoxicillin/ clavulanic
acid -ist line ( IDSA ) Amoxicillin or
Phenoxymethypenicillin( CKS )Clindamycin a 3rd
gen cephalosporin(if allergic to penicillin )
Doxycyline suitable alternativeQuinolones may
be tried if treatment with above not
possibleImaging Testing- Clinical diagnosis
based on history and examination No investigation
indicated in uncomplicated acute sinusitis CT
examination of choice Not required in acute
sinusitis MRI if complication is suspected XR
obsolete but can show air fluid levels indicate
bacterial cause size and integrity of para-nasal
sinuses Ultrasound conflicting evidence can be
combined with radiography Sinus culture
endoscopic or sinus puncturePre-existing
co-motbidity as? significant heart , lung , renal
, liver or neuromuscular disease?
Immunosuppression? Cystic fibrosis Acute cough
and older than 65 with two risk factors Acute
cough and older than 80 with one risk factor?
hospitilization in previous year? type 1 or 2
diabetes? congestive heart failure? on oral
steroid therapyChronic Rhinosinusitis
American Academy of Otolaryngology- Head and Neck
Surgery Criteria for diagnosing chronic
rhinosinusitis 12 or more weeks of 2 or more of
the following symptoms- mucopurulent discharge-
nasal obstruction- facial pain/ pressure /
fullness- decreased sense of smell AND
Inflammation by one or more objective criteria
endoscopy pus , mucosal edema or polyps imaging
showing inflammation of the paranasal
sinuses.It is one of the most common diseases
with an estimated prevalence of 4.5 to 12 in
N America and European countries It is the impact
on the general QoL with symptoms like diminished
sleep , productivity , cognition, mood and
fatigue? ( as well as sinonasal symptoms ) which
influences patients decision to elect a surgical
intervention Etiology is not understood
completely but inflammation rather than infection
is considered to be the dominant etiology Two
major subtypes of CRS are recognised- CRS with or
without polyps and it is this distinction which
guides management ?( as per latest EPOS guideline
)Referral ENT-Frequent recurrent episodes
Unremitting or progressive facial pain Nasal
polyps causing sig obstruction Trial of
intranasal steroids for 3 months with no benefit
Immunodeficiency Complication suspected Suspected
allergic or immunological aetiology and
associated co-morbidities as asthma Structural
anomalies as deviated nasal septum Sinus surgery
indicated

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ReferencesSinusitis Imaging Medscape Jan
2016Acute sinusitis Medscape Jan 2017
https//emedicine.medscape.com/article/232670-over
viewRudmik L, Soler ZM. Medical Therapies for
Adult Chronic Sinusitis A Systematic Review.
JAMA. 2015314(9)926939. doi10.1001/jama.2015.7
544 https//jamanetwork.com/journals/jama/article-
abstract/2432168Pocket Guide EPOS European
Position Paper on Rhinosinusitis and Nasal Polyps
2012 www.rhinologyjournal.comRosenfeld, R. M.,
Piccirillo, J. F., Chandrasekhar, S. S., Brook,
I., Ashok Kumar, K., Kramper, M., Corrigan, M.
D. (2015). Clinical Practice Guideline (Update)
Adult Sinusitis. OtolaryngologyHead and Neck
Surgery, 152(2_suppl), S1S39. https//doi.org/10.
1177/0194599815572097BMJ Best Practice Acute
sinusitis https//bestpractice.bmj.com/topics/en-g
b/14A guide to the management of acute
rhinosinusitis in primary care management
strategy based on best evidence and recent
European guidelines Br J Gen Pract 63 (616 )
611-613 https//www.ncbi.nlm.nih.gov/pmc/articles/
PMC3809423/NICE CKS Sinusitis October 2013
https//cks.nice.org.uk/sinusitisSinusitis and
its management BMJ 2007 33435810-minute
consultation sinusitis BMJ 2007 3341165RACGP
Ear , nose and throat Sinusitis Volume 45 , No 6
June 2016 Pages 374-377BSACI guidelines for the
management of rhinosinusitis and nasal polyposis
Clinical and Experimental Allergy , 38 , 260-275
https//onlinelibrary.wiley.com/doi/pdf/10.1111/j.
1365-2222.2007.02889.xDiagnosis and management
of rhinosinusitis a practice parameter update
Annals of Allergy , Asthma and Immunology ,
2014-10-01 , Volume 113 , Issue 4 , Pages
347-385Venekamp RP, Thompson MJ, Hayward G,
Heneghan CJ, Del Mar CB, Perera R, Glasziou
PP, Rovers MM. Systemic corticosteroids for
acute sinusitis. Cochrane Database of Systematic
Reviews 2014, Issue 3. Art. No. CD008115. DOI
10.1002/14651858.CD008115.pub3.Updates in the
management of chronic rhinosinusitis Anna
Slovick1, Jennifer Long1 Claire Hopkins,1
1Guys Hospital, Great Maze Pond, London, UK,
SE1 9RT https//www.openaccessjournals.com/article
s/updates-in-the-management-of-chronic-rhinosinusi
tis.pdf Cain, Rachel B, and Devyani Lal. Update
on the management of chronic rhinosinusitis.
Infection and drug resistance vol. 6 (2013)
1-14. doi10.2147/IDR.S26134Chronic
rhinosinusitis Epidemiology and burden of
disease. DeConde AS1, Soler ZM. Am J Rhinol
Allergy. 2016 Mar-Apr30(2)134-9. doi
10.2500/ajra.2016.30.4297

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