Sinusitis

by Katja Žalman and Gregor Prosen

Introduction

Sinusitis is one of the most common infections treated by emergency physicians and affects about 1 in 8 adults in the north America. It is the fifth most common diagnosis for which antibiotics are prescribed.
Sinusitis is an inflammation of the paranasal sinuses (frontal, maxillary, ethmoid and sphenoid).

A healthy sinus is sterile and lined with a thin layer of mucus that traps dust, germs and other particles in the air. Tiny, hair-like projections in the sinuses seep the mucus towards ostial opening that leads to the back of the throat, and then they slide down to the stomach.

Sinusitis rarely occurs without concurrent rhinitis and inflammation of the contiguous, nasal mucosa is simultaneously involved, and therefore the preferred term for this condition is rhinosinusitis.

Rhinosinusitis is classified according to the new guidelines (2015) by duration as;

acute rhinosinusitis (ARS) – when the illness appears less than 4 week
chronic rhinosinusitis (CRS) when lasting more than 12 weeks, with or without acute exacerbations. Chronic rhinosinusitis should be confirmed as the clinical diagnosis. Objective documentation of sinonasal inflammation may be achieved using anterior rhinoscopy, nasal endoscopy or computed tomography.

The different subgroups of acute rhinosinusitis are based on the duration of symptoms and signs, into acute bacterial rhinosinusitis (ABRS) or viral rhinosinusitis (VRS). Four or more episodes of rhinosinusitis per year, without persistent symptoms in between, the state is termed as recurrent ARS.

The acute rhinosinusitis is most frequently (90%) associated with viral upper respiratory tract infection. It is the most important risk factor for the development of acute bacterial sinusitis and it is most often caused by rhinovirus, coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus.

The most common occlusions that leads to bacterial overgrowth and excess mucus production are allergies, trauma and fractures, mechanical obstruction from tumors, abnormal anatomy, weaker immune system, nasal polyps and also nasogastric and nasotracheal intubation. The primary pathogens responsible for acute bacterial and recurrent ARS are Streptococcus pneumonia, non-typable H. influenza, and M. catarrhalis.

In chronic sinusitis, however, anaerobic bacteria, streptococcal species, S. aureus and also fungi (Rhizopus, Aspergillus, Candida, Histoplasma, Blastomyces, Coccidioides, and Cryptococcus species) play role.

Case Presentation

The 32-year-old married woman presented with nasal stuffiness with yellow nasal drainage, pain over the cheek, obstructed nose, facial pain and pressure, subjective fever and chills, mildly productive cough and overall malaise for ten days. She has used over-the-counter medication without significant benefit. She smoke three packs of cigarettes per week. She takes no medications and denies chronic medical diseases.

She is conscious (GCS 15), alert and oriented. BP 125/78, HR 77/min, RR 19 breaths/min, body temperature 38 °C. HEENT exam shows intact external ocular muscles, pupils are equal, round and reactive to light, red swollen nasal mucosa with thick yellow-green discharge. No polyps noted. Right maxillary and frontal sinuses are tender to palpation. Mild erythema noted on posterior oropharynx. External ear canals have no edema or erythema. The tympanic membranes are neither bulging or retracted; the ear landmarks are easily identifiable. The neck is supple without lymphadenopathy. The chest is clear to auscultation bilaterally.

Critical Bedside Actions and General Approach

First, check conditions and vital signs of the patient, and stabilize them if necessary. The most of the patients are rarely need any intervention during the primary evaluation (ABC) stage. When the patient is stable, we can continue with taking the history and physical exam, list of differential diagnoses, general diagnostic and appropriate treatments. The acute care of a patient diagnosed with acute rhinosinusitis is to eradicate infection, decrease severity and duration of symptoms and prevent complications.

Differential Diagnosis

The diagnosis of rhinosinusitis consists of the combination of clinical history, physical examination, imaging studies, and laboratory tests.

Conditions that predispose to rhinosinusitis are

Allergic and nonallergic rhinitis
Anatomic abnormality of the ostiomeatal complex
Aspirin sensitivity
Associated conditions: asthma, otitis media
Churg Strauss sydrome
Cilliary dyskinesia,
Cocaine abuse
Cystic fibrosis
GERD
Immune diseases and immunocompromised status
Instumentation (nasogastric and nasotracheal intubation)
Kartagener syndrome,
Nasal anatomic variants
Nasal polyps
Rhinitis medicamentosa
Trauma
Tumors
Young syndrome

Differential diagnosis of rhinosinusitis

Allergic rhinitis (seasonal, perennial)
Anatomic abnormalities (foreign body, nasal polyps, nasal septal deviation, enlarged tonsils and adenoids)
Cerebral spinal fluid rhinorrhea
Concha bullosa and other middle turbinate abnormalities
Infectious rhinitis (viral upper tract infections)
Nonallergic rhinitis (vasomotor rhinitis, aspirin tolerance, eosinophilic nonallergic rhinitis
Rhinitis medicamentosa (decongestants, β – blockers, birth control pills, antihypertensives)
Rhinitis secondary to: pregnancy, hypothyroidsm, horner sindrom, weger granulomatosis – midline granuloma
Tumors
Vascular headache (migraine)

History And Physical Examination Hints

Before we start the focused physical exam, which is based on an examination of the respiratory system, we have to take a look at a patient’s history and have to be especially focused on:

signs and symptoms (major and minor)
questions on allergic symptoms (sneezing, watery rhinorrhea, nasal itching and itchy watery), asthma and immunocompromising disorders
history of previous episodes of rhinosinusitis
history or possibility of trauma, fractures, nasal anatomic variants and anatomic abnormality of the ostiomeatal complex
active or passive smoking
current medications

Symptoms associated with rhinosinusitis are divided into major and minor groups. Combinations of these symptoms provide a diagnosis based on the patient’s history, viewed by anterior rhinoscopy, or as a postnasal discharge on pharyngeal examination.

Major Symptoms

Facial pain/pressure/fullness
Fever (for acute sinusitis only)
Hyposmia/anosmia
Nasal obstruction/blockage
Nasal or postnasal discharge/purulence

Minor Symptoms

Cough
Dental pain
Ear pain/pressure/fullness
Fatigue
Fever (for subacute or chronic sinusitis)
Halitosis
Headaches

Acute rhinosinusitis is diagnosed when a patient presents with up to 4 weeks of purulent nasal drainage, nasal obstruction, facial pain-pressure-fullness, or all of these symptoms. When a patient meets the criteria for ARS, the clinician should distinguish between viral rhinosinusitis (VRS) and bacterial ABRS. It can be difficult to distinguish between acute viral from acute bacterial sinusitis.

P – Facial pain, pressure or fullness (may involve the anterior face, periorbital region or manifest with headache)
O – Nasal obstruction (congestion, blockage, stuffiness)
D – Nasal purulence or discolored postnasal discharge (infected, colored, oozing)
S – Hyposmia or anosmia (smell)

Acute rhinosinusitis typically progresses over a period of 7 to 10 days; it is mostly self-limited and resolves spontaneously.

During a viral upper respiratory tract infection, three common clinical presentations should guide the clinician to think that it is an episode of acute bacterial sinusitis: persistent symptoms, severe symptoms, or worsening symptoms.

1. When symptoms or signs (PODS) – the presence of ≥ 2 PODS symptoms, one of which must be O or D of ARS lasting for more than 10 days but less than 30 days without any evidence of clinical improvement.
Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent (infected, colored or oozing) nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of the illness.
Onset with worsening symptoms or signs characterized by the new fever (fever is present in some patients with VRS in the first few days of illness but does not predict bacterial infection as an isolated diagnostic criterion – it has a sensitivity and specificity of only about 50% for ABRS), headache, dental pain, or increase in nasal discharge, following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (“double-worsening”).

Chronic rhinosinusitis is diagnosed when a patient presented greater than 12 weeks of anterior or posterior mucopurulent drainage, nasal obstruction, facial-pain-pressure-fullness and decreased the sense of smell.

Invasive fungal sinusitis usually occurs in immunocompromised patients and patients with diabetes. It is generally associated with fever, nasal pain, cloudy rhinorrhea, and affected turbinates by dark, thick and greasy material.

The anterior rhinoscopic examination is best performed after the application of a topical decongestant. The status of the nasal mucosa, the presence and color of nasal discharge should be evaluated. Predisposing anatomical variations can also be noted during anterior rhinoscopy.

The endoscopic examination should be used in selected patients with chronic or recurrent sinusitis, in the patient with rhinosinusitis who do not respond to therapy as expected, and in younger children in whom a medical history is deemed unreliable. Endoscopy provides ideal direct visualization of the nasal cavity, and anatomical structures such as Eustachian tube orifice, tonsils, posterior tongue, epiglottis, glottis, and vocal cords. The nasal polyps can be identified, as well as the presence of purulent ostial secretions. Endoscopy is usually performed by otolaryngologists. Therefore, emergency physicians should chose the patients who needs proper referral.

Emergency Diagnostic Tests and Interpretation

Imaging

In the majority of patients with rhinosinusitis, radiographic imaging is unnecessary in case of meeting diagnostic criteria for acute rhinosinusitis. Imaging procedures are useful when symptoms are vague, in poor response to initial management, comorbidities that predispose complications, atypical presentation and a history of trauma.

Ultrasound is safe, rapid and noninvasive for evaluating only the maxillary and frontal sinuses. The A-mode may be useful for screening the fluid in the maxillary sinus, and the B-mode detecting fluid in the cavity, mucosal thickening, or soft tissue mass in the maxillary sinus.

X-rays is not recommended for patients who have already met the clinical diagnostic criteria for ABRS. Radiography cannot be used to distinguish between bacterial and viral etiologies.

X-rays includes 3 different projections:

Waters view (occipitofrontal) – for maxillary and frontal sinuses
Caldwell view (angled posteroanterior) – only that visualizes the ethmoid air cells
Lateral view – visualize the sphenoid sinus and primary for adenoids in children

Radiographic findings of acute sinusitis are;

Diffuse opacification,
Mucosal thickening (>4 mm), or an air-fluid level.
Mild-to-moderate mucosal thickening, however, is a nonspecific finding.

X-ray – The Waters view shows air fluid level on the right maxillary sinus, and loss of air on the left maxillary sinus. Air presence is also decreased in ethmoidal sinuses.

CT is not used for routine evaluation and is limited to chronic and recurrent sinusitis, causes of questionable diagnose, patients with unresponsive disease, immunocompromised patients with fever, dentomaxillary pain or investigation of complications (severe headache, facial swelling, cranial nerve palsies, or forward displacement or bulging of the eye – proptosis). More than 50% of patients with a recent upper respiratory infection have abnormal findings on CT scan. On the CT with acute rhinosinusitis, we can find opacification, air-fluid level, and severe mucosal thickening.

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rID: 4890

MRI is not used for routine evaluation. MRI is a sensitive technique for evaluating suspected fungal sinusitis and for differentiating between inflammatory disease and malignancy.

Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org. From the case rID: 31870

Laboratory Tests

Complete blood cell count (CVC) is generally not specific, and it is unnecessary for the majority of patients with uncomplicated rhinosinusitis. In most cases, the results show that the CBC may be within normal ranges.

Higher level of erythrocyte sedimentation and C-reactive protein level can be seen in patients. Both of them are not specific.

Nasal cytology can be useful with variety of syndromes, including allergic rhinitis, bacterial sinusitis, eosinophilia, nasal polyposos, and aspirin sensitivity.

The culture of secretions from the nasal cavity or nasopharynx do not differentiate ABRS from VRS and are not routinely obtained unless in immunocompromised, intensive care patients and patients with complications of rhinosinusitis.

Emergency Treatment Options

Viral rhinosinusitis (VRS) treatment

Viral rhinosinusitis is a self-limited disease that occurs from 2 to 5 times per year in the average adult. Decongestant therapy such as topical steroids, topical and/or oral decongestants, which can not be used more than 3 to 5 day, mucolytics, and intranasal saline spray. They may be used alone or in varying combinations. Analgesics or antipyretic drugs (acetaminophen, ibuprofen, or other nonsteroidal anti-inflammatory agents) may be given for pain and fever.

Bacterial rhinosinusitis (BRS) treatment

Delaying antibiotic treatment of ABRS for up to 7 days after diagnosis is the current approach. This allows the infection get better on its own. If not, prescribe initial antibiotic therapy for adults with uncomplicated ABRS.
The clinician must also consider the patient’s age, general health, cardiopulmonary status, and comorbid conditions when assessing suitability for watchful waiting.

When we decide to treat ABRS with an antibiotic, the commonly used drug for children and adults is amoxicillin (with or without clavulanate as first-line therapy). A period from 5 to 10 days regimen of amoxicillin 500 mg, 2 times a day is recommended by many as the first-line therapy. The acute sinusitis generally responds to treatment from 10 to 14 days. Some physicians continue treatment for 7 days after the patient is well to ensure complete eradication of the organism and prevent relapse.

For patients who do not respond to amoxicillin, allergic to or intolerant of amoxicillin, live in communities with a high incidence of resistant organisms, failure to respond within 48-72 hours, persistence of symptoms beyond 10-14 day the second-line therapy is the most commonly used, which include cephalosporins, macrolides or quinolones.

Adjunct therapy such as intranasal saline irrigations, intranasal corticosteroids and local topic decongestants (oxymetazoline hydrochloride) is recommended. Topical agents should be used for up to 5 days; as extended use results in rebound vasodilation and nasal obstruction, the condition is termed as “rhinitis medicamentosa.” Antihistamines are not recommended as adjunct therapy unless there are patients with a history of allergic rhinosinusitis.

In patients with complications of acute rhinosinusitis high-dose intravenous antibiotics, including cefuroxime, ceftriaxone, or ampicillin-sulbactam is recommended.

Pediatric, Geriatric, Pregnant Patient, and Other Considerations

The described procedures can also be used in the pediatric, geriatric and pregnant patient with rhinosinusitis.

Disposition Decisions

Patients with uncomplicated rhinosinusitis can be discharged home with prescription for decongestant therapy, nonsteroidal anti-inflammatory drugs and in the case of ABRH with appropriate antibiotics. All other patients with complications require additional work-up or admission.

References and Further Reading

Richard M. Rosenfeld, Jay F. Piccirillo, Sujana S. Chandrasekhar, et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology– Head and Neck Surgery 2015, Vol. 152(2S) S1–S39 © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015. Avaliable from: http://oto.sagepub.com/content/152/2_suppl.toc. Accessed April 20, 2016
Itzhak Brook, Department of Pediatrics, Georgetown University School of Medicine. Acute Sinusitis. Updated: Mar 22, 2016. Available from: http://emedicine.medscape.com/article/232670-overview. Accessed April 20, 2016
Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Mosby/Elsevier; 2010:975-977.
Raymond G. Slavin, MD, Sheldon L. Spector, MD, and I. Leonard Bernstein, MD. The diagnosis and management of sinusitis: A practice parameter update. J Allergy Clin Immunol 2005;116: S13-47. American Academy of Allergy, Asthma and Immunology. Available from: https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/sinusitis2005.pdf. Accessed April 19, 2016.
Anthony W. Chow, Michael S. Benninger, Itzhak Brook, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. 2012. Available: http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full. Accessed April 22, 2016.