Acute and Chronic Sinusitis

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Acute and Chronic Sinusitis

• A Practical Guide for Diagnosis and Treatment

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Presentation Facts

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Acknowledgments

• This is a presentation of the American Academy
  of Family Physicianssupported by an educational
  grant from Aventis Pharmaceuticals
• The AAFP gratefully acknowledges Harold H.
  Hedges, III, M.D.
• andSusan M. Pollart, M.D.for developing the
  content for the AAFP
• andHarold H. Hedges, III, M.D. for providing the
  photo images included in this slide presentation.

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Acknowledgments

• Harold H. Hedges, III, M.D.Private Practice
• Little Rock Family Practice Clinic
• Little Rock, Arkansas
• and
• Susan P. Pollart, M.D.Associate Professor of
  Family MedicineUniversity of Virginia Health
  SystemCharlottesville, Virginia

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Upon Completion of This Presentation You Should
be Able To

• 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)

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Rhinosinusitis May be Better Term Because

• Allergic or nonallergic rhinitis nearly always
  precedes sinusitis
• Sinusitis without rhinitis is rare
• Nasal discharge and congestion are prominent
  symptoms of sinusitis
• Nasal mucosa and sinus mucosa are similar and are
  contiguous

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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 in
  the asthmatic patient AAAI J,1996776-19.

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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

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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

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Normal Waters and Towne s Views of the Sinuses
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Lateral View Showing Normal Sphenoid Sinus
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Ostiomeatal Complex

• Ostiomeatal 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

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Viral Rhinosinusitis

• Most upper respiratory infections are viral
• Short lived, last less than 10 days
• Sinus mucosa as well as nasal mucosa is involved
• Most will clear without antibiotics
• Treatment decongestants, nasal lavage, rest,
  fluids

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Classification of Bacterial Sinusitis

• 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 gt90 days)
• Some guidelines add treatment failure a
  positive imaging study

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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

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Differentiating Sinusitis from Rhinitis

• Sinusitis
• Nasal congestion
• Purulent rhinorrhea
• Postnasal drip
• Headache
• Facial pain
• Anosmia
• Cough, fever

• Rhinitis
• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

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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

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X-Ray Image of Sinuses with Maxillary Sinusitis
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Pathogenesis of Nasal Obstruction

• Viral upper respiratory infections
• Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
• Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
• Deviated septum, concha bullosa, polyps

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Allergic Stimuli Causing Rhinosinusitis

• Pollens
• Tree, grass, weeds
• House dust mite
• Animal danders
• Cat, dog, mice, gerbil, other animals with fur
• Molds
• Allergic foods and beverages

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Nonallergic Stimuli Causing Rhinosinusitis

• Tobacco smoke
• Perfumes
• Cleaning solutions
• Potpourri
• Burning candles
• Cosmetics
• Car exhaust, diesel fumes
• Hair spray

• Cold air
• Dry air
• Changes in barometric pressure
• Auto exhaust
• Gas, diesel fuel
• Nonallergic foods
• Nonallergic beverages

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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
• Aspirin
• Anesthetic agents
• Benzodiazepines

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Diseases Slowing Ciliary Function

• Allergic and nonallergic rhinitis
• Rhinosinusitis
• Aging rhinitis
• Cystic fibrosis
• Any disease causing obstruction, crusting of the
  mucosa

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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
• Sjogrens syndrome
• Sarcoidosis
• Wegener granulomatosis

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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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Acute Bacterial Sinusitis

• 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
• Severetemperature of 102, purulent nasal
  discharge for 3-4 days, child appears ill
• Disease clears with appropriate medical treatment

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Physical Findings

• Mucopurulent nasal discharge
• Highest positive predictive value
• Swelling of nasal mucosa
• Mild erythema
• Facial pain (unusual in children)
• Periorbital swelling

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Objectives of Treatment of Acute Bacterial
Sinusitis

• Decrease time of recovery
• Prevent chronic disease
• Decrease exacerbations of asthma or other
  secondary diseases
• Do so in a cost-effective way!

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Treatment of Acute Sinusitis

• Antihistamines recommended if allergy present
• Oral or topical
• Decongestants
• Oral or topical
• Antibiotic when indicated (bacteria)
• Nasal irrigation
• Guaifenesin 200-400 mg q4-6 hrs
• Hydration

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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
• Oral
• Pseudoephedrine 30-60 mg
• Phenylephrine 2-4 times/day

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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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Additional Antibiotics for Acute Bacterial
Sinusitis

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

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Nasal Irrigation

• Commercial buffered sprays
• Bulb syringe
• 1/4 tsp of salt to 7 ounces water
• Waterpik with lavage tip
• 1 tsp salt to reservoir
• Disposable enema bucket
• 2 tsp salt, 1 tsp soda per quart of water

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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

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Nasal Irrigation

• With enema bucket/hose.
• Add 2 teaspoons of salt and 1 tsp of baking soda
  to a quart of warm water
• 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

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When Medical Therapy for Acute Bacterial
Sinusitis Fails

• 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)

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Sinus Transillumination

• Helpful in older children and adults
• Normal transillumination decreases chance of pus
  in the sinus
• No light reflex suggests mucopurulent material or
  thickening of nasal mucosa
• Inexpensive screening tool

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Sinus Transillumination

• 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 light

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Photo Image of Sinus Transilluminator
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Transillumination of Frontal Sinus
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Transillumination of Maxillary Sinus
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Rhinoscopy Aids in Diagnosing

• Nasal polyps
• Septal deviation
• Concha bullosa
• Eustachian tube dysfunction
• Causes of hoarseness
• Adenoid hyperplasia
• Tumors

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Rhinoscope
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CT Scan Maxillary and Ethmoid Sinuses
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MRI Imaging

• Not used for imaging suspected acute sinusitis
• Suspected fungal sinusitis
• Suspected tumors

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Bacteria Involved in Acute Bacterial Sinusitis

• Streptococcus pneumoniae 30
• Haemophilus influenza 20
• Moraxella catarrhalis 20
• Sterile 30

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Comparison of Various Approaches to the
Treatment of AR
Sneezing Discharge Itch Congestion Side
Effects Antihistaminestraditional
(A) Non-sedating(NSA)
to Azelastine to
Decongestants NSA
decongestants Leukotriene
antag. to to to to
Cromolyn Nasal CCS
(NCS) NSA NCS
Immunotherapy to
Presumed no data on individual symptoms. Nayak
AS, et al. Ann Allergy Asthma Immunol.
200288592-600. Strongly positive
effect Minimal effect
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Rational for Starting Rx with Amoxicillin

• In the absence of risk factors, i.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 -- if 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

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Optimal Duration of Antibiotics

• Give antibiotic until patient free of symptoms
  then add 7 days

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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

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Quality-of-Life Issues

• Fatigue
• Concentration
• Nuisance
• Sleep disturbance
• Emotional well being
• Social interactions

• Missing school/work
• Halitosis
• Decreased production
• Impaired studying
• Sniffing/snorting
• Blowing nose

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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
• Cystic fibrosis
• Tumors
• Immunodeficiency disorders
• IgA, IgM
• Granulomatous diseases

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Evaluation of Chronic Sinusitis

• CT or MRI scanning
• Anatomic defects, tumors, fungi
• Allergy testing
• Inhalants, fungi, foods
• Sinus aspiration for cultures
• Bacterial
• Fungal
• Immunoglobulins

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Treatment of Chronic Sinusitis

• Nasal steroid spray
• Guafenesin
• Decongestants
• Steam inhalation
• Nasal irrigation
• Antibiotics with exacerbations

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Bacteria Involved in Chronic Sinusitis Role of
Viruses is Unknown

• Streptococcus pneumoniae
• Haemophilus influenza
• Moraxella catarrhalis
• Staph aureus
• Coagulase negative staphylococcus
• Anerobic bacteria

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Transition of Bacteria Rom Acute to Chronic
Sinusitis

• 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
  antibiotics
• Brook I, et al. Bacteriology and beta-lactamase
  activity in acute and chronic maxillary
  sinusitis. Arch Otolaryngol Head Neck Surg
  1996122418-23.

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Sinus Aspiration and Culture

• Correlation of routine nasal culture and sinus
  culture are poor
• Endoscopically guided aspiration of cultures from
  medial meatus do correlate with sinus culture
• Gold SM, Tami TA. Role of middle meatus
  aspiration culture in the diagnosis of chronic
  sinusitis. Laryngoscope 1997107 1586.

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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

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Complications of Sinusitis

• Orbital
• Diplopia, proptosis
• Periorbital erythema, swelling
• Bone
• Periosteal abscesses
• Brain
• Intracranial abscesses causing neurologic
  symptoms

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The Sinusitis-Asthma Connection

• Mechanism is not understood
• Evidence is compelling
• Failure to control upper airway inflammation
  leads to suboptimal asthma control
• Correcting the rhinosinusitis results in better
  asthma control

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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

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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

• 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
  diseaseexpert opinion was used when insufficient
  data could be found.

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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.

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Recommendation 2a

• 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 (gt10 days, lt 30
  days) predicted abnormal radiographs 80 of the
  time
• Children lt 6 symptoms predicted 88 of the time
• Normal x-ray suggests ABS is not present

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Recommendation 2b

• CT scans of the paranasal sinuses should be
  reserved for
• Patients in whom surgery is being considered as a
  management strategy
• Patients who do not respond to medical regimes
  which include adequate antibiotic use
• Assisting in diagnosis of anatomical changes
  interfering with airflow or drainage

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Recommendations for CT Scans

• Patients presenting with complications of
  sinusitis
• Neurologic symptoms, diplopia, periorbital or
  facial swelling with or without erythema
• Patients with sinus symptoms accompanied by
  severe, boring, mid-head pain
• Rule out sphenoid sinusitis

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Recommendation 3

• Antibiotics are recommended for the management of
  acute bacterial sinusitis to achieve a more rapid
  clinical cure
• Patients must meet requirements of persistent or
  severe disease
• Response improved with doses gtMinimal Inhibition
  Concentration

77
No EB Recommendations Found for Use of Adjunctive
Therapy in ABS, May be Helpful

• Nasal saline irrigation
• Oral decongestants
• Oral or nasal antihistamines
• Topical decongestants
• Mucolytic agents
• Topical steroids

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Summary

• Acute and chronic sinusitis is one of the most
  common diseases treated in family practice
• It is important to treat sinusitis aggressively
  to prevent chronic symptoms or development of
  serious complications
• The underlying causes of chronic sinus disease
  should be sought out and corrected

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Additional Bibliography

• Dykewicz M. Rhinitis and Sinusitis. J All Clin
  Immunol, 2003 111S520-9.
• Hamilos DL. J Allergy Clin Immunol
  2000106213-27.
• Kaliner MA. Current Review of Rhinitis. Current
  Medicine, Inc., 2002.
• Kaliner MA. Current Review of Allergic Diseases.
  Current Medicine, Inc., 2000.
• Agency for Healthcare Research and Quality
• American Academy of Pediatrics
• New England Medical Center Evidence-based
  Practice Center

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Evidence-Based Recommendations

• Practice Recommendation Reduce unnecessary use
  of antibiotics. Providers should be consistent
  with the recommended criteria for prescribing
  antibiotics in acute sinusitis endorsed by the
  CDC, American Academy of Family Physicians, the
  American College of Physicians-American Society
  of Internal Medicine, and the Infectious Diseases
  Society of America.
• Practice Recommendation Use first line
  antibiotics, which are amoxicillin or
  trimethoprim-sulphamethoxazole (TMP/SMX).
• Practice Recommendation Use an antibiotic that
  covers resistant bacteria (amoxicillin-clavulanate
  Augmentin or another second line agent) to
  treat patients if failed on 10-14 days of
  amoxicillin.
• All recommendations available at
  http//www.icsi.org/knowledge/detail.asp?catID29
  itemID148. Accesses August 2003.

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Thank You
This has been a presentation of the American
Academy of Family Physicians