Sinusitis

Sinus infection accounts for close to 16 million office visits per year ( USA ). Sinusitis is more common from early fall to early spring. It is much more common in adults than children. approximately 0.5 % of upper respiratory tract infections are complicated by sinusitis. Acute sinusitis is the second most common infectious disease seen by GPs ( Acute sinusitis Can Fam Physician 2011). This review covers acute sinusitis presentation.

Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses .

 Inflammation of the sinus cavities is almost always accompanied
 by inflammation of the nasal cavities – 
RHINOSINUSITIS is a more suitable and preferred term

Obstruction of sinus drainage pathways Ciliary impairment Altered mucus quantity and quality

Causes risk factors – Viral infection- most common cause and include
○ Respiratory syncytial virus
♦ Rhinovirus
♦ Parainfluenza
♦ Influenza with rhinovirus
 Acute bacterial infection
Following an episode of viral sinusitis 0.5 % to 2 % cases will progress to acute bacterial sinusitis

Sinusitis is one of the commonest reasons a healthcare professional will prescribe an antibiotic

Most commonly implicated bacteria are
♣ Streptococcus pneumoniae
♦ Haemophilus influenzae 
 Allergic and non-allergic rhinitis
 Anatomical variations
♦ abnormality of osteomeatal complex
♦ septal deviation 
♦ cleft palate
♦ concha bullosa – pneumatized ( air filled ) cavity withih a turbinate in the nose ( Google )
♦ hypertrophic middle turbinates
 Cigarette smoking –> can damage cilia Asthma – chronic sinusitis and nasal polyps Diabetes – risk chronic sinusitis Swimming , diving , high altitude climbing Dental infections and procedures Diagnosed more frequently in women than men Aspirin sensitivity.Cystic fibrosis Neoplasia Mechanical ventilation Use of nasal tubes such as NG feeding tubes Sarcoidosis Immunodeficiency Wegeners granulomatosis Sinus surgery Immotile cilia syndrome

Presentation- Most common cause of acute sinusitis is a viral infection – usually follows a common cold Clinical findings may include Pain over cheek – radiating to frontal region or teeth ↑↑ with straining or bending down Facial pain or pressure Headache Persistent cough ( ↑↑ at night ) Tenderness pressure over the floor of the frontal sinuses immediately above inner canthus Nasal blockage ( obstruction / congestion ) Disoloured nasal discharge ( ant / post nasal drip ) Hyposmia – reduced sense smell Toothache

Acute Bacterial Sinusitis -ABRS- Discoloured discharge 
○ unilateral predominance
♦ purulent secretions in the nasal cavity
 Severe local pain ( unilateral predominance )
 Fever > 38°
 Elevated ESR / CRP
 Double sickening – a deterioration after an initial milder phase of illness. Caused by a virus in
 > 98 % cases takes an 
average 2.5 weeks to resolve
 and antibiotics only likely to 
help if features suggestive 
of bacterial infection

Examination- Inspect and palpate the maxillofacial area Check nasal cavity- rhinoscopy for
♠ nasal inflammation
♦ mucosal oedema
♦ mucupurulent nasal discharge
♦ nasal polyps
♦ anatomical abnormalities eg deviated nasal septum
♦ nasal foreign body
♦ sinonasal tumour

Caution- Periorbital oedema / erythema Displaced globe Double vision Ophthalmoplegia Reduced visual acuity


 Severe frontal headache Swelling over frontal bone Symptoms and signs of
meningitis Focal neurological signs

Management- Paracetamol or NSAID
 Intranasal decongestant
Topical agents preferred over systemic
Up to 3-5 days – prevent rebound congestion
eg Oxymetazoline nasal spray
 Intranasal corticosteroid
patients with congestion
low systemic SEs
advised min 1 month use
 Irrigating nose with nasal saline solution Warm face packs Adequate hydration Ipratropium – if congested ( topical anticholinergic )

Immunocompromised or severe illness-High dose amoxicillin/ clavulanic acid -
ist line ( IDSA ) 
Amoxicillin or Phenoxymethypenicillin
( CKS )
 Clindamycin + a 3rd gen cephalosporin
(if allergic to penicillin )
 Doxycyline suitable alternative
 Quinolones – may be tried if treatment with above not possible

Imaging – Testing- Clinical diagnosis based on history and examination No investigation indicated in uncomplicated acute sinusitis CT – examination of choice
Not required in acute sinusitis MRI – if complication is suspected XR – obsolete but can show
air fluid levels – indicate bacterial cause 
size and integrity of para-nasal sinuses Ultrasound – conflicting evidence can be combined with radiography Sinus culture – endoscopic or sinus puncture

Pre-existing co-motbidity as
♦ significant heart , lung , renal , liver or neuromuscular disease
♦ Immunosuppression
♦ Cystic fibrosis
 Acute cough and older than 65 with two risk factors
Acute cough and older than 80 with one risk factor
♦ hospitilization in previous year
♦ type 1 or 2 diabetes
♦ congestive heart failure
♦ on oral steroid therapy

Chronic Rhinosinusitis – American Academy of Otolaryngology- Head and Neck Surgery Criteria for diagnosing chronic rhinosinusitis
 12 or more weeks of 2 or more of the following symptoms
- mucopurulent discharge
- nasal obstruction
- facial pain/ pressure / fullness
- decreased sense of smell

AND
 Inflammation by one or more objective criteria
- endoscopy : pus , mucosal edema or polyps
- imaging showing inflammation of the paranasal sinuses.
It is one of the most common diseases with an estimated prevalence of 4.5 % to 12 % in N America and European countries It is the impact on the general QoL with symptoms like diminished sleep , productivity , cognition, mood and fatigue
 ( as well as sinonasal symptoms ) which influences patients decision to elect a surgical intervention Etiology is not understood completely but inflammation rather than infection is considered to be the dominant etiology Two major subtypes of CRS are recognised- CRS with or without polyps and it is this distinction which guides management 
( as per latest EPOS guideline )

Referral ENT-Frequent recurrent episodes Unremitting or progressive facial pain Nasal polyps – causing sig obstruction Trial of intranasal steroids for 3 months with no benefit Immunodeficiency Complication suspected Suspected allergic or immunological aetiology and associated co-morbidities as asthma Structural anomalies as deviated nasal septum Sinus surgery indicated

References

1. Sinusitis Imaging Medscape Jan 2016
2. Acute sinusitis Medscape Jan 2017 https://emedicine.medscape.com/article/232670-overview
3. Rudmik L, Soler ZM. Medical Therapies for Adult Chronic Sinusitis: A Systematic Review. JAMA. 2015;314(9):926–939. doi:10.1001/jama.2015.7544 https://jamanetwork.com/journals/jama/article-abstract/2432168
4. Pocket Guide EPOS – European Position Paper on Rhinosinusitis and Nasal Polyps 2012 www.rhinologyjournal.com
5. Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Ashok Kumar, K., Kramper, M., … Corrigan, M. D. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1–S39. https://doi.org/10.1177/0194599815572097
6. BMJ Best Practice ; Acute sinusitis https://bestpractice.bmj.com/topics/en-gb/14
7. A guide to the management of acute rhinosinusitis in primary care management strategy based on best evidence and recent European guidelines Br J Gen Pract ; 63 (616 ) : 611-613 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809423/
8. NICE CKS Sinusitis October 2013 https://cks.nice.org.uk/sinusitis
9. Sinusitis and its management BMJ 2007 ;334:358
10. 10-minute consultation : sinusitis BMJ 2007 ;334:1165
11. RACGP Ear , nose and throat Sinusitis Volume 45 , No 6 June 2016 Pages 374-377
12. BSACI guidelines for the management of rhinosinusitis and nasal polyposis Clinical and Experimental Allergy , 38 , 260-275 https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2222.2007.02889.x
13. Diagnosis and management of rhinosinusitis : a practice parameter update Annals of Allergy , Asthma and Immunology , 2014-10-01 , Volume 113 , Issue 4 , Pages 347-385
14. Venekamp  RP, Thompson  MJ, Hayward  G, Heneghan  CJ, Del Mar  CB, Perera  R, Glasziou  PP, Rovers  MM. Systemic corticosteroids for acute sinusitis. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008115. DOI: 10.1002/14651858.CD008115.pub3.
15. Updates in the management of chronic rhinosinusitis Anna Slovick1, Jennifer Long1 & Claire Hopkins*,1 1Guy’s Hospital, Great Maze Pond,  London, UK, SE1 9RT https://www.openaccessjournals.com/articles/updates-in-the-management-of-chronic-rhinosinusitis.pdf 
16. Cain, Rachel B, and Devyani Lal. “Update on the management of chronic rhinosinusitis.” Infection and drug resistance vol. 6 (2013): 1-14. doi:10.2147/IDR.S26134
17. Chronic rhinosinusitis: Epidemiology and burden of disease. DeConde AS¹, Soler ZM. Am J Rhinol Allergy. 2016 Mar-Apr;30(2):134-9. doi: 10.2500/ajra.2016.30.4297