Resident Editors: Luis Rubio, M.D.

Faculty Editor: Ralph Gonzales, M.D.

Background

• Definition: Mucosal inflammation of the nasal cavity and paranasal sinuses
  • Acute rhinosinusitis <4 weeks
  • Subacute rhinosinusitis 4-12 weeks
  • Chronic rhinosinusitis >12 weeks
  • Recurrent acute rhinosinusitis- >4 episodes of acute rhinosinusitis with interim resolution
• Acute rhinosinusitis can be further classified on etiology:
  • Acute viral rhinosinusitis (AVRS)
  • Uncomplicated acute bacterial rhinosinusitis (ABRS)- bacterial etiology without clinically evident extension outside paranasal sinuses and nasal cavity (no neurologic, ophthalmic, or soft tissue involvement)
  • Complicated ABRS- bacterial etiology with extension outside paranasal sinuses and nasal cavity
• Predisposing factors to acute bacterial rhinosinusitis: viral infection (~2% of viral URIs progress to bacterial sinusitis), nasal allergy, impaired mucociliary clearance (cigarette smoking, cystic fibrosis), dental/periodontal disease, nasal obstruction due to polyps, foreign bodies or tumors
• In acute bacterial rhinosinusitis, Strep pneumoniae and H. flu > Moraxella catarrhalis > staph species and anaerobic infections.  
• Fungus in the paranasal sinuses is a common finding.  However, in an immunocompromised patient (poorly controlled DM, neutropenia from chemotherapy) fungal infection, likely mucor, can spread through surrounding soft tissue and bone.  Invasive Fungal Sinusitis (IFS) is a medical emergency requiring IV antifungals and likely aggressive surgery.
• Important diagnoses to exclude in differential diagnosis: orbital or postseptal cellulitis, cavernous sinus thrombosis, IFS, other ascending infection.

Signs and Symptoms

• Major: purulent nasal discharge, nasal congestion, facial pain or pressure, hyposmia, and posterior purulent drainage
• Minor: headache, fever, halitosis, fatigue, dental pain, cough, ear pain/pressure/fullness
• Red Flags: proptosis, diplopia with decreased extra-ocular movements, severe headache with high fever, periorbital edema or cellulitis, mental status change, eye pain (most sensitive sign for orbital cellulitis).

Evaluation / Diagnosis

• Diagnosis is clinical. According to the IDSA, ABRS in setting of viral URI should be considered when
  • (1) major/minor signs/symptoms are present 10 days or more beyond the onset of upper respiratory symptoms, or 
  • (2) major/minor signs/symptoms worsen within 10 days after initial improvement (called “double-sickening”)
  • (3) fever > 39°C with purulent nasal discharge or facial pain for 3-4 days at the beginning of an illness.  
• Recurrent acute rhinosinusitis: 4 or more episodes of acute rhinosinusitis per year, each lasting longer than 7-10 days, with complete resolution of signs/symptoms in between episodes (distinguishes it from chronic rhinosinusitis)

• Chronic rhinosinusitis: persistent symptoms lasting > 12 weeks in duration.  May have intermittent flare-ups.  Role of bacteria more complex than in acute disease.
  • Requires more complex workup including sinus CT, endoscopy, allergy evaluation and consideration of rheumatologic or immunologic causes.
• Labs/tests – unnecessary in diagnosing ABRS. CT is valuable if concern for facial/orbital spread or structural precipitant. Role of culture discussed further in treatment section.

Treatment

• Acute rhinosinusitis is a self-limiting disease in most cases
• Treatment of rhinosinusitis should focus on two key principles:
  • Establish and promote sinus drainage 
    • Saline irrigation (high volume ~30ml, ex Neti pot) BID to TID for comfort and helpful in patients with frequent sinus infections.
    • Intranasal glucocorticoids most beneficial for patients with underlying allergic rhinitis. Small benefit seen in viral or bacterial sinusits.
    • Nasal decongestants (Oxymetazoline [Afrin]): Can be used for immediate symptom relief, but should not be used for more than 3 days to prevent dependence and rebound phenomenon. 
  • Treat bacterial infection, if ABRS suspected
    • When to treat with antibiotics: When IDSA criteria for bacterial sinusitis are met (see evaluation/diagnosis above): 10 or more days of symptoms, 5-6 days of severe symptoms, or double sickening.
    • First line treatment: amoxicillin-clavulanate for 5-7 days.
      • High dose amoxicillin-clavulanate (2grams BiD) in places with >10% penicillin-nonsusceptible strep pneumo (NOT true at Moffitt, VA, or SFGH) or for pts who are febrile > 39°C and ill-appearing, > 65 years, recent hospitalization, abx use within past month, or immunocompromised.
      • Doxycycline (first line) or a respiratory fluroquinolone (levofloxacin, moxifloxacin) are acceptable alternatives in penicillin-allergic patients.
      • Macrolides and TMP-SMX are not recommended due to high rates of resistance 
    • Treating recurrent or resistant disease: 
      • If worsening after 72 hrs of antibiotics or no improvement after 3-5 days of antibiotics, consider switching antibiotics and evaluate for antibiotic resistance, non-infectious etiology, structural abnormality or other causes of treatment failure
      • If infection persists after first and second line antibiotic therapy, pursue culture via endoscopic middle meatus sampling or direct sinus aspiration. Culture of nasopharyngeal swabs and purulent nasal discharge culture have no value.
• Chronic rhinosinusitis treatment is complex and is usually managed in conjunction with specialists (allergy, ENT). These treatment modalities are based on etiology and reviewing them is beyond the scope of this primary care text. Components include long-term topical nasal steroids, saline irrigations and adjunctive therapies such as leukotriene inhibitors. For more detail see Hamilos article below.

When to refer

• Emergent surgical evaluation or send to the emergency department if signs of intracranial or orbital extension (see Red Flags above)
• Patients with recurrent acute sinusitis (≥ 4/year) or chronic sinusitis (> 12 weeks) should be evaluated for allergy and immunodeficiency and referred to ENT for evaluation of possible anatomic abnormalities.
• Other indications for referral to specialist includes, but not limited to resistant pathogens, fungal sinusitis, anatomic defects requiring surgical intervention, immunocompromised host, evaluation of immunotherapy for allergic rhinitis. 

References

Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.

Hamilos DL. Chronic rhinosinusitis: epidemiology and medical management. J. All Clin Immunology 2011; 128(4) 693-707

Hwang PH, Getz A, Deschler DG, et al.  Acute sinusitis and rhinosinusitis in adults: clinical manifestations and diagnosis. In: UpToDate, Sokol HN (Ed), UpToDate, Waltham, MA, 2012.

Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.