Sinusitis resident survival guide: Difference between revisions
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*During history taking ask for prior upper respiratory infections, use of tobacco, anatomic anomalies, acid reflux disease, and immunologic state. | *During history taking ask for prior upper respiratory infections, use of tobacco, anatomic anomalies, acid reflux disease, and immunologic state. | ||
*Look after major and minor signs of sinusitis: | *Look after major and minor signs of sinusitis: | ||
*Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, fever | **Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, and fever | ||
*Minor: | **Minor: headache, cough, halitosis, fatigue, otalgia, and dental pain | ||
*During physical examination look for purulent nasal discharge, rhinolalia, edema, periorbitary erythema, and pain to palpation and percussion to the frontomaxilary region | |||
==Don'ts== | ==Don'ts== | ||
* Avoid inappropriate use of antibiotics in acute presentations since the vast majority of these infections are viral. | *Avoid inappropriate use of antibiotics in acute presentations since the vast majority of these infections are viral. | ||
* Avoid ordering imaging studies in cases where the diagnosis is well established clinically. | *Avoid ordering imaging studies in cases where the diagnosis is well established clinically. | ||
==References== | ==References== | ||
Revision as of 17:02, 25 August 2020
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:[1][2]
- 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, Head, and Neck Surgery guidelines:[3]
| 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
- During history taking ask for the exposure to toxins, toxic waste, wood, immersion in contaminated water, solvents, gas or oil refineries, leather tanning, textiles, drug addictions, and chronic administration of intranasal drugs.
- During history taking ask for prior upper respiratory infections, use of tobacco, anatomic anomalies, acid reflux disease, and immunologic state.
- Look after major and minor signs of sinusitis:
- Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, and fever
- Minor: headache, cough, halitosis, fatigue, otalgia, and dental pain
- During physical examination look for purulent nasal discharge, rhinolalia, edema, periorbitary erythema, and pain to palpation and percussion to the frontomaxilary region
Don'ts
- Avoid inappropriate use of antibiotics in acute presentations since the vast majority of these infections are viral.
- Avoid ordering imaging studies in cases where the diagnosis is well established clinically.
References
- ↑ Brook I (2011). "Microbiology of sinusitis". Proc Am Thorac Soc. 8 (1): 90–100. doi:10.1513/pats.201006-038RN. PMID 21364226.
- ↑ deShazo RD, Chapin K, Swain RE (1997). "Fungal sinusitis". N. Engl. J. Med. 337 (4): 254–9. doi:10.1056/NEJM199707243370407. PMID 9227932.
- ↑ Rosenfeld, Richard M.; Piccirillo, Jay F.; Chandrasekhar, Sujana S.; Brook, Itzhak; Ashok Kumar, Kaparaboyna; Kramper, Maggie; Orlandi, Richard R.; Palmer, James N.; Patel, Zara M.; Peters, Anju; Walsh, Sandra A.; Corrigan, Maureen D. (2015). "Clinical Practice Guideline (Update): Adult Sinusitis". Otolaryngology–Head and Neck Surgery. 152 (2_suppl): S1–S39. doi:10.1177/0194599815572097. ISSN 0194-5998.