Sinusitis

Overview:

• Sinusitis involves a wide spectrum of presentations, both acute and chronic.
• It is primarily a medical condition, with surgical management reserved for complicated or refractory cases.
• Sinusitis is an inflammatory condition affecting the nose and paranasal sinuses.

Prevalence:

• Approximately 1.4 in every 100 general practice encounters are for acute or chronic sinusitis.
• In 2011 and 2012, an estimated 1.9 million Australians had chronic rhinosinusitis.

Anatomy:

Paranasal Sinuses:

• The paranasal sinuses are paired structures and include:
  • Frontal Sinuses
  • Maxillary Sinuses
  • Ethmoid Air Cells
  • Sphenoid Air Cells
• Drainage Pathways:
  • Frontal, Maxillary, and Anterior Ethmoid Cells: Drain to the middle meatus.
  • Posterior Ethmoid and Sphenoid Cells: Drain to the superior meatus.
• The maxillary sinus is the largest air-filled sinus in the body, but its ostium is only about 2.4 mm in diameter.

Mucociliary System:

• The nose and paranasal sinuses are lined with ciliated, pseudostratified columnar epithelium.
• Goblet cells produce mucus, forming a mucociliary blanket that traps noxious particles.
• Cilia transport these trapped particles from the sinus to the nasopharynx.

Pathophysiology:

• Environmental and host factors can lead to inflammation or anatomical/physiological alterations, disrupting mucociliary clearance.
• The target of both medical and surgical treatment is to restore and assist mucociliary clearance.

Diagnostic criteria (from the European Position Paper on Rhinosinusitis)

Adult Acute Rhinosinusitis:

• Criteria:
  • Sudden onset of two or more symptoms, one of which should be either:
    • Nasal blockage/congestion/obstruction
    • Nasal discharge (anterior or posterior)
  • Plus:
    • Facial pain/pressure and/or
    • Reduction or loss of smell
  • Symptoms last less than 4 weeks
• Note:
  • For patients with symptoms lasting 4 to 12 weeks, the same assessment and management considerations apply as for patients with acute rhinosinusitis. However, a bacterial cause may be more likely than a viral cause.

Adult Chronic Rhinosinusitis:

• Criteria:
  • Symptoms persisting for more than 12 weeks

Paediatric Acute Rhinosinusitis:

• Criteria:
  • Sudden onset of two or more symptoms:
    • Nasal blockage/congestion/obstruction
    • Discoloured nasal discharge
    • Cough (day and night time)

Paediatric Chronic Rhinosinusitis:

• Criteria:
  • Symptoms persisting for more than 12 weeks

Acute rhinosinusitis (ARS)

1. Common cold (acute viral rhinosinusitis)
2. Post-viral ARS
   • an increase of symptoms after five days, or persistence of symptoms after 10 day
3. Acute bacterial rhinosinusitis
   • <2% of episodes of viral upper respiratory tract infections are complicated by bacterial transformation
   • yet primary care physicians prescribe antibiotics for >85% of presentations of sinusitis
   • can occur in
     • immunocompromised patients
     • patients with odontogenic infection
     • deficient mucociliary clearance mechanisms
     • mechanical nasal obstruction
   • At least three of:
     • often with a unilateral predominance
     • Discoloured
     • purulent nasal discharge
     • Severe, localised pain
     • Fever >38°C
     • Elevated erythrocyte sedimentation rate/C-reactive protein
     • Double sickening
       • patient deteriorates after a period of mild illness

---

Clinical assessment

The signs and symptoms of acute viral and bacterial rhinosinusitis overlap considerably, especially during the first 3 to 4 days of illness.

If the patient presents in the first 3 to 4 days of illness, manage as for viral rhinosinusitis, as this is the most likely cause of symptoms.

After the first 3 to 4 days of illness, the clinical course may help to distinguish between acute viral and bacterial rhinosinusitis.

symptoms

• discharge
• changes in smell
• cough (in children)
• Facial pain
  • often worsens on bending forward
  • can radiate to the teeth

Examination

• presence of discharge (clear mucus or purulent material)
• polyposis
• swelling
• erythema
• Oral examination
  • postnasal discharge
  • exclude dental disease

Features of acute viral and bacterial rhinosinustis

Feature	Acute viral rhinosinusitis	Acute bacterial rhinosinusitis
Fever	Often present in the first few days of illness.	is generally preceded by a viral or post-viral ARSHigh fever (39°C or higher) present at the onset of illness and persisting for 3 to 4 consecutive days.Fever has a sensitivity and specificity of about 50% for predicting acute bacterial rhinosinusitis
Symptom onset	Symptoms peak rapidly and decline by the third day of illness.	Severe symptoms can occur at the onset of illness and persist for 3 to 4 consecutive days.Severe symptoms are defined as high fever (39°C or higher) plus purulent nasal discharge or facial pain.
Symptom duration and improvement	Symptoms resolve by 7 days in 75% of patients. In 25% of patients, symptoms last longer than 7 days but reduce in severity.	Symptoms usually resolve or improve within 7 to 14 days, but bacterial infection is more likely if:symptoms persist for longer than 7 to 10 days without improvementsymptoms worsen after initial improvement.

---

Imaging

• Clinical assessment is normally sufficient for diagnosis
• Plain X-rays yield little information
• CT nose and paranasal sinuses
  • not recommended routinely, especially in children.
  • reserved for cases where complications are suspected

---

Management

Acute Viral Rhinosinusitis

1. Regular oral analgesia
   • paracetamol/NSAIDs
   • recommended in all patients
2. Saline nasal preparations (sprays, rinses or drops)
   • may reduce sinus symptoms and improve the patient’s quality of life.
   • particularly beneficial for patients with recurrent episodes of acute rhinosinusitis
   • Patient education:
     • correct use of nasal saline irrigations is vital to ensure appropriate delivery and patient compliance.
     • Patients should be told to boil water to ensure sterility and allow to cool so it is approximately at body temperature or ‘warm’ prior to use.
     • The delivery system should be aimed at 45 degrees towards the outer eye.
3. Intranasal corticosteroids
   • moderately improve symptoms of acute rhinosinusitis
   • A Cochrane review found a modest benefit with intranasal steroids, which may be used if symptoms persist.
   • Treatment should be continued for 7–14 days. Patients should be advised of the need to re-present if any red flag symptoms should arise
4. Intranasal and systemic decongestants
   • beneficial if congestion is the prominent symptom
   • recommended for short-term use only (up to 5 days) in adults and children 6 years or older.
5. Intranasal ipratropium bromide
   1. is beneficial if rhinorrhoea is the prominent symptom
6. Oral corticosteroids
   1. should only be used for acute rhinosinusitis under specialist advice.
7. Antihistamines
   1. do not relieve symptoms of acute rhinosinusitis
   2. they should only be considered if allergy is likely to be contributing to symptoms.
8. Antibiotics
   • Routine use of antibiotics to treat ARS in primary care does not prevent the development of complications.

Acute bacterial rhinosinusitis

• Initially treat patients with suspected acute bacterial rhinosinusitis with symptomatic therapy alone, with follow-up if symptoms worsen or do not improve as
  • Primary bacterial infection is rare, and secondary bacterial infection occurs in less than 2% of patients.
  • Acute bacterial rhinosinusitis is usually a self-limiting condition and antibiotics make little difference to the course of the illness.
  • If antibiotics are prescribed, the rate of symptom improvement is increased at days 3 and 7, but at day 10, there is no difference in improvement between patients treated with or without antibiotics.
  • The use of antibiotics for acute bacterial rhinosinusitis does not prevent the occurrence of rare complications, such as complicated acute bacterial rhinosinusitis.
  • The small benefit of antibiotic therapy must be balanced against the potential harms
    •  diarrhoea
    • rash
    • hypersensitivity reactions
    • bacterial resistance
  • For every 100 patients treated with antibiotics for acute bacterial rhinosinusitis, 12 patients will experience an antibiotic adverse effect.

• Shared decision making in acute bacterial rhinosinusitis
  • Many patients have an expectation of treatment with antibiotics.
  • Effective communication with the patient or carer about the limited role of antibiotics in acute bacterial rhinosinusitis is essential.
  • make health decisions in partnership, informed by the best available evidence and the patient or carer’s values and preferences.
  • Patients who take part in shared decision making have a more accurate understanding of the benefits and harms of the available treatment approaches, and are more likely to choose conservative management.

explain to patient:

Reassurance:

• Acute bacterial rhinosinusitis (a sinus infection) is usually self-limiting, which means it often gets better on its own.
• Complications are rare, and using antibiotics doesn’t prevent these rare complications.

Treatment Approaches:

1. Symptomatic Therapy Alone:
   • We can focus on relieving the patient’s symptoms with medications like pain relievers and decongestants.
   • If the patient’s symptoms don’t improve in 5 days or if they worsen, we will reassess and decide if further treatment is needed.
2. Symptomatic Therapy Plus a Delayed Antibiotic Prescription:
   • We can provide medications to relieve symptoms and also provide an antibiotic prescription for the patient to use if they can’t return for a follow-up and their symptoms don’t improve in 5 days.
3. Symptomatic Therapy Plus Immediate Antibiotic Prescription:
   • We can start the patient on antibiotics right away along with medications to relieve their symptoms.

Expected Course:

• Most people see their symptoms resolve or improve within 7 to 14 days without antibiotics.

Acknowledge the Patient’s Experience:

• We understand that the patient’s symptoms are affecting their daily life and can be very frustrating.

Antibiotics:

• Antibiotics can offer limited benefits, even if the infection is bacterial.
• They may speed up symptom improvement slightly by days 3 and 7, but by day 10, there is usually no difference between those who took antibiotics and those who didn’t.

Potential Harms of Antibiotics:

• Antibiotics can cause side effects like diarrhea, rash, allergic reactions, yeast infections, and even a serious infection called Clostridium difficile.
• They can also lead to antibiotic resistance, making future infections harder to treat.
• Out of every 100 patients treated with antibiotics for this condition, about 12 will experience side effects.

Patient’s Preferences and Concerns:

• Let’s discuss the patient’s preferences, values, and any concerns they have.
• Feel free to ask any questions.

Making a Decision Together:

• We’ll make a decision together based on the patient’s situation and preferences.

Follow-Up:

• If the patient’s symptoms don’t improve in 5 days, or if they worsen, especially if they develop a fever, please return for reassessment.
• If the patient has symptoms suggesting a more complicated infection, contact us immediately

Antibiotic regimens for acute bacterial rhinosinusitis

• Amoxicillin 500 mg (child: 15 mg/kg up to 500 mg) orally, 8-hourly for 5 days,
• If adherence to an 8-hourly regimen is unlikely, a 12-hourly regimen can be used instead. Use: amoxicillin 1 g (child: 30 mg/kg up to 1 g) orally, 12-hourly for 5 days

immediate nonsevere/delayed nonsevere hypersensitivity to penicillins, use:

• cefuroxime 500 mg (child 3 months or older: 15 mg/kg up to 500 mg) orally, 12-hourly for 5 days; see Patient review and modification of therapy[Note 1].    

immediate severe or delayed severe hypersensitivity to penicillins, use:

• doxycycline orally, 12-hourly for 5 days
  • adult: 100 mg
  • child 8 years or older and less than 26 kg: 50 mg
  • child 8 years or older and 26 to 35 kg: 75 mg
  • child 8 years or older and more than 35 kg: 100 mg
• OR (for children younger than 8 years or children requiring an oral liquid formulation)
• trimethoprim+sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 160+800 mg orally, 12-hourly for 5 days; see Patient review and modification of therapy.

---

RED FLAG Symptoms

1. Unilateral symptoms
2. Bleeding
3. Cacosmia (perceived malodorous smell)
4. Signs of meningitis (neck stiffness, photophobia)
5. Altered neurology
6. Frontal swelling
7. Any orbital involvement:

• Diplopia
• Decreased visual acuity
• Painful ophthalmoplegia
• Peri-orbital oedema and erythema
• Globe displacement

Complications of ARS

Incidence of Complications:

• Complications occur in approximately 3 per million population per year.
• This translates to:
  • 1 in 12,000 episodes of ARS in children.
  • 1 in 32,000 episodes of ARS in adults.

Types of Complications:

1. Orbital Complications:
   • Occur twice as often as intracranial complications.
   • Present with symptoms such as:
     • Painful ophthalmoplegia (eye movement pain and difficulty).
     • Diplopia (double vision).
     • Proptosis (bulging of the eye).
     • Decreased visual acuity.
   • Loss of green/red color differentiation may be the first sign of decreased visual acuity; Ishihara plates should be used for testing.
2. Intracranial Complications:
   • Less common than orbital complications but serious.
3. Osseus Complications:
   • These are the least common type of complications.

Referral:

• Immediate referral to an ear, nose, and throat (ENT) specialist is crucial if complications are suspected.
• Complications can cause significant morbidity and mortality if left untreated.

---

Chronic rhinosinusitis

• contributing factors:
  • bacterial infection
  • allergy
  • cystic fibrosis
  • physical obstruction (including nasal polyps or anatomical variation)
  • swelling of the mucosa
  • mucociliary impairment
  • immune deficiency
  • prolonged use of intranasal decongestants (rhinitis medicamentosa)

Clinical assessment

• Anterior rhinoscopy
  • to check presence or absence of polyps
  • grape-like structure that are pearly or greyish-yellow (a markedly different colour from the nasal mucosa)
• computed tomography (CT)
  • mucosal changes in the osteomeatal complex or sinuses
  • nasal polyps
• serum-specific immunoglobulin E (IgE) tests (‘RAST’ testing) If any allergic symptoms
  • sneezing, watery rhinorrhoea
  • nasal itch and itchy
  • watery eyes
• Facial pain
  • It is important to note that diagnosis of sinusitis requires the presence of either nasal congestion or discharge.
  • Facial pain is often misdiagnosed as sinusitis, but it is rarely a significant feature of chronic sinusitis.
  • In a survey of CRSwNP, only 16% of patients reported moderate or severe facial pain.
  • It is important to consider other diagnoses when pain is the predominant feature, to avoid the patient going untreated while waiting for otolaryngologist review.
  • Other causes of facial pain:
    • Migraine
    • Trigeminal neuralgia
    • Cluster headache
    • Paroxysmal hemicrania
    • Atypical facial pain
    • Tension headache
    • Chronic oro-facial pain
    • Dental infection
    • Mid-facial segment pain
    • Post-herpetic neuralgia

• Initial management
  • trial of topical steroids and nasal irrigation for at least eight weeks.
  • Topical steroids can be delivered as a nasal spray or in conjunction with the nasal irrigation,
  • through addition of diprosone OV cream or budesonide respules to the rinse once a day.
  • Nasal saline irrigation should be conducted at least twice daily to mechanically lavage the contents of the sinuses.

specific management:

Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)

Treatment for Nasal Polyps:

1. Testing:
   • In Children: Test for cystic fibrosis.
   • In Adults: Test for coexisting asthma and aspirin sensitivity (aspirin-exacerbated respiratory disease).
2. Medical Polypectomy:
   • Oral Steroids: A Cochrane review found that a short course of oral steroids significantly reduces polyp size and improves sinonasal symptoms.
     • Prednisolone Dosage:
       • 25 mg orally, once daily for 1 week.
       • Then 12.5 mg once daily for 1 week.
       • Then 12.5 mg on alternate days for 1 week.
   • Maintenance Therapy:
     • Continue with topical steroids and nasal irrigation to maintain polyp reduction.
     • Consider adding macrolide therapy for at least eight weeks to enhance mucociliary function, reduce inflammatory cytokines, and possibly reduce polyp size.
3. Surgical Polypectomy:
   • Indicated if medical polypectomy is ineffective or if symptoms recur.
   • Functional Endoscopic Sinus Surgery (FESS):
     • Involves endoscopic removal of polyps and ventilation of sinus cells.
     • Major Complications (rare):
       • Damage to extraocular muscles, loss of vision, cerebrospinal fluid leak, and meningitis.
     • Post-Surgery Care:
       • Intranasal corticosteroid therapy must be continued long-term to prevent or delay recurrence.

Patient Awareness:

• CRS is an inflammatory condition of the mucosa. Sinus surgery is not a cure but an attempt to allow better symptom control.

Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP)

Treatment:

1. Oral Corticosteroids:
   • Can be used in adults with uncontrolled symptoms while awaiting specialist management.
   • Prednis(ol)one Dosage:
     • 25 mg orally, once daily for 5 to 10 days.
2. Specialist Referral:
   • If symptoms do not respond after at least 1 month of initial therapy, refer to a specialist for further management.