Acute and Chronic Sinusitis

Acute and Chronic Sinusitis
A Practical Guide for Diagnosis and Treatment Bibliography Clinical Guidelines:Management of Sinusitis, Pediatrics, Volume 108 Number 3, September 2001 Kaliner, M A. Current Reviews of Rhinitis,, editor, Current Medicine 2002 McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273: McAlister WH, et al. Imaging of sinusitis in children. Pediatr Infect Dis J. 1999;18: Dykewicz,MS, The difficult asthmatic. Imm and All Clinics of North America, Vol21,Num3.August 2001

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Number of slides: 81 Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation These slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE

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

Acknowledgments and 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 Medicine University of Virginia Health System Charlottesville, Virginia

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)

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

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 Third most common diagnosis for which antibiotics are prescribed. Rhinosinusitis, like asthma is becoming more prevalent. McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:

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,1996;77:6-19.

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 The ostia of the maxillary sinuses is situated up 2/3 of the wall of the sinus. Drainage occurs by the washing of mucus containing virus, bacteria and other material by ciliary action. Any thing that interferes with ciliary action (tobacco smoke, antihistamines) may predispose the sinus to infection. Healthy sinuses depend on ciliary action and aeration. Kaplan, second edition. Allergy. Chapter 26:

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 Physiologic reasons for sinuses not totally understood. The above are suggestions as to their role. Kaplan, second edition. Allergy. Chapter 26:

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

Normal Water’s and Towne’ s Views of the Sinuses

Lateral View Showing Normal Sphenoid Sinus

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

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

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 days) Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days) Some guidelines add treatment failure + a positive imaging study

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

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

Differentiating Sinusitis from Rhinitis
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

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

X-Ray Image of Sinuses with Maxillary Sinusitis

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

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

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

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 Hydration is important in treating sinusitis. Hydration will aid in decreasing the viscosity of secretions. Cilia are damaged by “cold” viruses, the effect may last several weeks. Pedersen M, et al. Nasal mucociliary transport, number of ciliated cells, and beating patters in naturally occurring colds.Euro J Resp Dis. Supplement 128:355,1983 Euro J Resp Dis. Supplement 128:355,1983

Diseases Slowing Ciliary Function
Allergic and nonallergic rhinitis Rhinosinusitis Aging rhinitis Cystic fibrosis Any disease causing obstruction, crusting of the mucosa

Causes of Mechanical Obstruction
Deviated nasal septum Concha bullosa Foreign body Nasal polyps Congenital atresia Lymphoid hyperplasia Nasal structural changes found in Downs syndrome

Vasculitides, Autoimmune and Granulomatous Diseases
Churg-Strauss vasculitis Systemic lupus erythematosis Sjogren’s syndrome Sarcoidosis Wegener granulomatosis

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

Acute Bacterial Sinusitis
Usually begins with viral upper respiratory illness Symptoms initially improve, but then … Symptoms become persistent or severe Persistent… days but fewer than 4 weeks Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill Disease clears with appropriate medical treatment

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

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!

Treatment of Acute Sinusitis
Antihistamines recommended if allergy present Oral or topical Decongestants Antibiotic when indicated (bacteria) Nasal irrigation Guaifenesin mg q4-6 hrs Hydration

Decongestants Topical nasal sprays (limit use to 3-7 days)
Phenylephrine Oxymetazoline Naphthazoline Tetrahydrozoline Zylometazoline Topical nasal spray (unlimited daily use) Ipatropium Oral Pseudoephedrine mg Phenylephrine 2-4 times/day

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

Antibiotics for Acute Bacterial Sinusitis
Amoxicillin 500 mg tid for 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

Additional Antibiotics for Acute Bacterial Sinusitis
Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum ( 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 Give prescription for antibiotic for 5 days, if no response switch to another, if responding refill for full 10 day course. Where co-pays are involved give entire 10 day prescription initially.

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

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

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

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)

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

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

Photo Image of Sinus Transilluminator

Transillumination of Frontal Sinus

Transillumination of Maxillary Sinus

Rhinoscopy Aids in Diagnosing
Nasal polyps Septal deviation Concha bullosa Eustachian tube dysfunction Causes of hoarseness Adenoid hyperplasia Tumors

Rhinoscope

CT Scan Maxillary and Ethmoid Sinuses

MRI Imaging Not used for imaging suspected acute sinusitis
Suspected fungal sinusitis Suspected tumors

Bacteria Involved in Acute Bacterial Sinusitis
Streptococcus pneumoniae 30% Haemophilus influenza 20% Moraxella catarrhalis 20% Sterile 30% Staph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS.

Comparison of Various Approaches to the Treatment of AR
Sneezing Discharge Itch Congestion Side Effects Antihistamines traditional (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 ;88: ++++ = Strongly positive effect; += Minimal effect

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 Choosing an antibiotic should be based on the prevalence of bacterial species, prevalence of resistance, and the rate of spontaneous improvement. 15% of children with strep pneumoniae, 50% with h. influenza and 50-75% M.catarrhalis recover spontaneously.

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

Secondary Antibiotics for Acute Sinusitis
Cefdinir (Omnicef) Cefuroxime (Ceftin) Cephpodoxime (Vantin) Azithromycin Clarithromycin Trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole should not be used first or second line therapy because of pneumococcal resistance.

Optimal Duration of Antibiotics
Give antibiotic until patient free of symptoms then add 7 days Optimal duration has not been studied thoroughly and empiric recommendations have been made of days. Using symptom free plus 7 days individualizes time for each patient and gives a minimum of 10 days therapy.

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

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

Sx of Chronic Sinusitis
Nasal discharge Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down)

Conditions Causing Chronic Sinusitis
Allergic and nonallergic rhinitis Uncorrected anatomic conditions Ciliary dyskinesia Cystic fibrosis Tumors Immunodeficiency disorders IgA, IgM Granulomatous diseases

Evaluation of Chronic Sinusitis
CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal Immunoglobulins Correction of anatomic defects, drainage of infected sinuses, immunotherapy for IgE mediated allergies, treatment of immunoglobulinemias can alter the course of chronic sinusitis. Unfortunately there are a significant number who have no demonstrable cause for this chronic disease and do not respond to medication .

Treatment of Chronic Sinusitis
Nasal steroid spray Guafenesin Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations

Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown
Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria Staph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS.

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 1996;122;

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 1997;107: 1586.

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 If prophylactic antibiotics are contemplated or used need to evaluate for allergy, immunodeficiency, cystic fibrosis, ciliary dyskinesia, anatomic abnormalities.

Complications of Sinusitis
Orbital Diplopia, proptosis Periorbital erythema, swelling Bone Periosteal abscesses Brain Intracranial abscesses causing neurologic symptoms Cellulitis can spread around the eye and cheek indicated by swelling and erythema. Symptoms of meningitis, severe headache, focal neurologic symptoms signal spread to intracranial areas.

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 Dykewicz,MS, The difficult asthmatic. Imm and All Clinics of North America, Vol21,Num3.August 2001 Several studies have demonstrated that both medical and surgical treatment of sinusitis have led to improvement in asthma. Studies have also shown that treatment with cetrizine, loratadine, and oral decongestants improved asthma with concomitant allergic rhinosinusitis..

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 Family physicians can readily learn to screen patients for allergy and complete testing for geographic relevant allergens when appropriate. The use of multiple allergen applicators is safe, very cost effective and easy to learn. It allows early diagnosis of the patient whose recurrent or chronic problems are allergic, helps to direct avoidance procedures, as well as aids in the selection of appropriate medication for rhinosinusitis.

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

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 disease…expert opinion was used when insufficient data could be found.

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.

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 (>10 days, < 30 days) predicted abnormal radiographs 80% of the time Children < 6 symptoms predicted 88% of the time Normal x-ray suggests ABS is not present

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 McAlister WH, et al. Imaging of sinusitis in children. Pediatr Infect Dis J. 1999;18:

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 The sphenoid sinus sits just anterior to the sella turcica. Sphenoid sinusitis usually does not occur alone but with a pan sinusitis and can be life threatening. Early diagnosis is important to decrease the chance of neurologic complications caused by extension of infection into the brain. Emergency surgery may be necessary

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 >Minimal Inhibition Concentration Gwaltney JM Jr. Acute community acquired sinusitis. Clin Infect Dis. 1996;

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 Very little data exists to recommend any of the above on scientific basis but can be helpful. Oral/nasal decongestants aid in airflow and patient comfort. Oral Antihistamines would aid the patient with allergic rhinitis predisposing to ABS. Astelazine, an antihistamine nasal spray has a non allergic indication and can be helpful. Saline irrigation removes allergic and non allergic triggers for rhinitis and gives symptomatic relief. It also decreased crust formation and helps liquefy secretions No data on mucolytic agents in ABS..

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

Additional Bibliography
Dykewicz M. Rhinitis and Sinusitis. J All Clin Immunol, 2003; 111:S520-9. Hamilos DL. J Allergy Clin Immunol 2000;106: 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

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 days of amoxicillin. All recommendations available at: Accesses August 2003.

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

Acute and Chronic Sinusitis

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