Otolaryngology for the Internist by David Oglethorpe, MD, James A. Hadley, MD. Medical Clinics of North America, vol. 83 (1), January 1999.
Background: Sinusitis is one of the most common health complaints leading to a physician visit in the US, as well as one of the leading causes for antibiotics prescriptions. In 1992, there were 73 million restricted activity days in patients with sinusitis and total direct medical costs of almost $2.4 billion (not including surgery or radiographic imaging). In 1993, 14.7% of people in the National Health Interview Survey had sinusitis the preceding year, with higher rates in the South, Midwest and in women. Children less than 15 years of age and adults aged 25-64 years of age are affected the most.
New term is rhinosinusitis because purulent sinus disease without similar rhinitis is rare.
4 classifications: Acute rhinosinusitis Sudden onset, lasting less than 4 weeks with complete resolution.
Subacute rhinosinusitis-A continuum of acute rhinosinusitis but less than 12 weeks.
Recurrent Acute Rhinosinusitis-4 or more episodes of acute, lasting at least 7 days each, in any 1 year period.
Chronic Rhinosinusits-Signs of symptoms persist 12 weeks or longer.
Causes are a combination of environmental and host factors:
1. Most commonly a viral upper respiratory infection causes rhinosinusitis secondary to edema and inflammation of the nasal lining and production of thick mucous that obstructs the paranasal sinuses and allows a secondary bacterial overgrowth.
2. Atopy
3. Anatomic defects such a septal deviations, conchae bullosa.
4. Impaired mucous transport from diseases such as cystic fibrosis, ciliary dyskinesia.
5. Immunodeficiency from chemotherapy, HIV, diabetes, etc.
6. Body positioning- ICU patients due to prolonged supine positioning that compromises mucociliary clearance.
7. Prolonged oxygen use due to drying of mucosal lining.
8. Patients with nasogastric or nasotracheal tubes.
History and Physical Findings
Major factors- Facial pain/pressure, facial congestion/fullness, nasal obstruction, nasal or postnasal purulence, hyposmia, fever
Minor factors(diagnostically significant only with one or more major factors)- Headache, halitosis, fatigue, dental pain, cough, otalgia
On exam, look for facial swelling, erythema, edema(most commonly periorbital), cervical adenopathy, postnasal drainage or pharyngitis. Anterior rhinoscopy may reveal mucosal edema, mucous crusting, frank purulence, obstructive polyps or other anatomical defects. Percuss the forehead and cheeks for deep tenderness. Transillumination of the sinuses may be helpful.
Laboratory and Radiographic Tests
No laboratory tests are indicated in the ED for acute uncomplicated sinusitis.
Plain sinus xray is most accurate for maxillary, frontal or sphenoid disease but is not useful for evaluating the anterior ethmoid cells or the osteomeatal complex from which most sinus disease originates. Coronal CT at a thickness of 3-4mm is the modality of choice.
Microbiology
15% of aspirates contain viruses.
Strep pneumo-3%, H. flu-21%, Anaerobes-6%, Staph aureus-4%, Strep pyogenes-2%, Moraxella-2%
Chronic- Staph aureus-20%, Anaerobes-3%, Strep pneumo-4%, Multiple organisms-16%
Allergic fungal incidence is 2-7%, most commonly aspergillis.
Pharmacotherapy
Humidification, decongestants (topical or systemic) such as pseudoephedrine. Remember oxymetolazone cannot be used for more than 3 days due to rebound congestion.
Antihistamines have not been shown to be useful and can lead to impaired drainage. Topical steroids are useful to diminish nasal mucosal edema but are more efficacious in chronic sinusitis.
Antibiotics- use empirically and base on community patterns of resistance.
Amoxicillin, amox/clavulanate, cefuroxime, cefprozil, cefpodoxime, cipro, levofloxacin. In some communities, amoxicillin effectiveness is less than 70%. Treat for 10-14 days.
Treatment for chronic sinusitis should cover Staph aureus and be effective against the higher incidence of B- lactamase producing organisms that are common in chronic disease. If the patient is not improving after 5-7 days, add metronidazole or clindamycin. Treat for 4 weeks.
