Rhinosinusitis

Acute Rhinosinusitis

• Diagnosed clinically using symptoms and signs >7d duration
  • Must have one of "OD" and one other "PODS" symptom
    • Facial Pain (or pressure), Nasal Obstruction, Discharge, Smell loss
  • Assess symptom severity based on tolerability/function
• Radiological imaging usually not required (unless diagnosis unclear)
  • X-ray (3 views) diagnosis with air/fluid level or complete opacification
  • CT scan if complication
• Most are viral and resolve spontaneously within 10-14d
  • Suspect bacterial if
    • Deterioration of symptoms 5-7d after improvement (biphasic)
    • Persistent symptoms without improvement >10-14d as per INESSS
      • >7d without improvement (or >10d persisting symptoms) as per Canadian guidelines
  • Treat bacterial if severe symptoms impacting function/sleep

History

• Alarm symptoms - Consider urgent referral to ER
  • Toxic, altered mental status
  • Persistent fever (>38C)
  • Periorbital erythema/swelling or decreased visual acuity
  • Meningeal signs/severe headache or neuro signs
• Symptoms: PODS, other (headache, cough, dental/ear pain, halitosis)
• Predisposing conditions
  • Recent viral URTI
  • History of allergic/nonallergic/medication-induced rhinitis
  • Concomitant conditions (pregnancy, immunodeficiency, migraine)
  • Anatomic causes (deviated septum, enlarged tonsils, nasal polyp)
• Response to medication, decongestant
• Exposure and previous antibiotics
• Facial pain increasing with leaning forward

Physical Exam

• Tenderness on palpation/percussion of sinus
  • Maxillary floor from palate
  • Lateral ethmoid wall from medial angle of eye
  • Frontal floor from roof of orbit
  • Anterior maxillary wall from cheek
  • Anterior front wall from supraorbital skull
• Maxillary teeth tenderness (using tongue depressor)
• Purulent secretions in middle meatus (using otoscope or nasal speculum)
• Posterior pharynx for purulent secretions (use pharyngeal mirror)

Treatment

• Prevention: Smoking cessation, hand hygiene
• Symptom management:
  • Analgesics (acetaminophen, NSAIDs)
  • Saline irrigation BID
  • Oral decongestants <10d (when worse congestion, eg. night)
    • Topical decongestants <3d (risk of rebound congestion)
• Consider topical intranasal corticosteroids (eg. nasonex) in mild-moderate ARS (NNT 15)
  • If no improvement after 72h, consider antibiotics

Antibiotics

• Consider treatment for suspected acute bacterial rhinosinusitis (as above) with severe symptoms or mild-moderate not responsive to INCS after 72h (NNT 17, NNH 8)
  • Amoxicillin 500mg PO q8h x 5-10 days
  • Second-line (or first-line if suspect resistance, immunosuppressed, frontal/sphenoidal sinusitis due to higher rates of complications)
    • Amoxicillin/Clavulanate 875/125mg PO BID x 7d
    • Moxifloxacin 400mg PO daily x 5d
    • Levofloxacin 500mg PO daily x 10d
  • If non-severe penicillin allergy, consider cefuroxime 250 BID x7d or cefixime 400 daily x10d
    • If anaphylaxis, consider clarithromycin, doxycycline or TMP-SMX

Follow-up

• Lack of response within 72h suggests treatment failure
• Referral to ENT if (and consider CT if long waiting time)
  • Complications
  • Persists >8w
  • Recurrent rhinosinusutis >3 episodes per year

Chronic rhinosinusitis

• Definition
  • Inflammation in paranasal sinuses and nasal passages >12 weeks despite medical treatment
• Treatment
  • Oral glucocorticoids PLUS empiric oral antibiotics x 4w
    • Prednisone 20mg PO BID x 5d, then 20mg daily x 5 days (total 10 days)
    • Amoxicillin-clavulanate 875mg PO BID or Clindamycin 450 mg PO TID
  • Topical glucocorticoid spray and intranasal saline irrigation or sprays