Sinusitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.

Overview

Rhinosinusitis is the inflammation of the nasal mucosa and paranasal sinuses. The terms sinusitis and rhinosinusitis are used interchangeably, although rhinosinusitis is preferred because inflammation of the paranasal sinuses rarely ever occurs without concurrent inflammation of the nasal mucosa. The cause of rhinosinusitis is mostly infectious, although it can be associated with other medical conditions such as allergies. The diagnosis is primarily clinical and imaging and other diagnostic studies are not necessary for diagnosis.

Causes

Life Threatening Causes

• Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
• There are no known causes of life-threatening causes of sinusitis.

Common Causes

Infectious causes of rhinosinusitis include viruses, bacteria, and fungi:

• Viruses
  • Rhinovirus
  • Influenza virus
  • Parainfluenza virus

• Bacteria
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Streptococcus pyogenes
  • Staphylococcus aureus: common in chronic sinusitis
  • Pseudomonas aeruginosa: common in nosocomial sinusitis, cystic fibrosis patients and the immunocompromised
  • Anaerobes: Prevotella, Fusobacterium and Peptostreptococcus: common in chronic sinusitis
• Fungi
  • Aspergillus species
  • Fusarium species
  • The Mucorales

Diagnosis and Treatment

Shown below is an algorithm summarizing the diagnosis and treatment of sinusitis according to the American Academy of Otolaryngology guidelines:

Adult with possible sinusitis

Duration ≤ 4w

Duration 4-12w

Duration ≥ 12w

No

Meets criteria for acute rhinosinusitis?

“Subacute” sinusitis excluded from guideline

Signs and symptoms of chronic rhinosinusitis?

No

Viral upper respiratory infection

Yes

Yes

Not chronic rhinosinusitis

No

Meets criteria for acute bacterial rhinosinusitis?

Yes

Acute bacterial rhinosinusitis

Documented sinonasal inflammation?

No

Viral acute rhinosinusitis

Yes

Complication suspected?

Yes

Obtain radiologic imaging

No

Chronic rhinosinusitis

Do not obtain radiologic imaging

Confirm the presence or absence of nasal polyps

No

Absense of complications?

Recommend symptomatic relief for acute bacterial rhinosinusitis

Recommend saline nasal irrigation and/or topical intranasal corticosteroids

Manage complication and acute bacterial rhinosinusitis

Offer watchful waiting OR prescribe antibiotic based on shared decision-making

Recommend saline nasal irrigation and/or topical intranasal corticosteroids

Do not prescribe topical or systemic antifungal therapy

Assess patient for chronic conditions that would modify management

Decision to proceed with watchful waiting

Decision to proceed with initial antibiotic therapy

Option of testing for allergy and immune function

Offer a safety-net or wait-and-see antibiotic prescription

Medical or surgical management as appropriate

Treatment failure

Yes

Prescribe amoxicillin, with or without clavulanate

No

Treatment failure?

Recurrent acute bacterial rhinosinusitis?

No

Yes

No

Exclude complications and other causes of illness; if diagnosis of acute bacterial rhinosinusitis is confirmed prescribe an alternate antibiotic

Management complete

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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