Rhinosinusitis
Acute Uncomplicated Rhinosinusitis
Pt with no significant PMH presents with acute onset maxillofacial pain and rhinorrhea that started < 10 days ago. Reports headache/sinus fullness, decreased sense of smell, cough. Denies purulent rhinorrhea, double sickening. Temperature < 38.3 C, sinus tenderness with palpation, and nasal mucosa inflammation on exam. No purulent nasal secretions noted.
Consider ESR, CRP
Recommend symptomatic treatment with trial of
Analgesics
Tylenol 650 mg q6h PRN pain
Naproxen 500 mg BID
Nasal saline irrigation PRN
Nasal corticosteroid: Fluticasone propionate 50 mcg two sprays in each nostril once daily
Decongestants: No h/o HTN or cardiovascular disease, consider
Afrin (oxymetazoline) nasal spray 2 sprays in each nostril BID for ≤ 3 days; pt counseled about potential for rebound symptoms s/p discontinuation
Pseudoephedrine PO 120 mg every 12 hours
Counseling
Pt counseled that symptoms are likely related to viral illness
Pt informed that no labs or imaging are indicated at this time
Pt encouraged to return for re-evaluation at 10 days s/p symptom onset or earlier s/he notes onset of purulent rhinorrhea, temperature > 101 F
Notes
Viral vs. bacterial
Factors that increase likelihood of bacterial etiology: Double sickening (initial improvement followed by worsening symptoms), purulent rhinorrhea/nasal cavity secretions, ESR > 10 mm per hour (see Acute Complicated Rhinosinusitis below for more information)
47% of bacterial sinusitis cases resolve by 7 days with or without antibiotics
Do not order imaging studies (e.g. plainfilm, CT) for acute, uncomplicated rhinosinusitis
Treatment
Moderate evidence supporting intranasal corticosteroids
Limited evidence supporting analgesics, saline irrigation, decongestants
Consider a “pocket prescription”
Reduces need for pt to return for f/u visit if symptoms do not improve
Include appropriate fill date, e.g. “Do not fill before [date = 10 days after symptoms started]”
Acute Complicated Rhinosinusitis
Pt with h/o HIV, dental infections, recent nasal packing, sinus surgery for deviated septum/nasal polyps, and smoking presents with acute onset severe maxillofacial pain and rhinorrhea lasting > 10 days. Reports headache/sinus fullness, decreased sense of smell, purulent rhinorrhea, cough. Endorses double sickening and recent, acute increase in symptom severity. Temperature > 38.3 C, sinus pain with palpation, and purulent rhinorrhea/nasal cavity secretions on exam.
ESR > 10 mm/hr and CRP > 49 mg/L indicating increased likelihood of bacterial infection
Imaging
No initial imaging indicated
Treatment failure (see below) and/or concern for rare complications:
Obtain non-contrast CT of the sinuses
Consider referral to ENT (see below)
Treatment
Start Augmentin 875 mg BID x 7 days if the patient meets the following criteria
Purulent nasal discharge with nasal obstruction + facial pain/pressure
Severe symptoms during first 3-4 days of illness
Symptoms worsening during first 7 days or persisting after 7 days
Augmentin allergy or initial treatment failure: Verify no h/o prolonged QT interval and start levofloxacin 500 mg qd x 10 days
May continue to use analgesics, saline irrigations, nasal corticosteroids, decongestants if desired
Refer to ENT for any of the following
Complicated health history
H/o immunocompromised state (e.g. HIV)
Concern for malignancy or other serious illness
Current illness severity
Temperature > 39 C
Continued worsening despite initial (Augmentin) and repeat (levofloxacin) treatment
Three or more episodes of rhinosinusitis within one year
Notes
Most commonly associated bacteria: S. pneumoniae, H. influenzae, and M. catarrhalis
Factors that increase risk for sinus bacterial infection:
HIV or other immunodeficiency
Recent/repeat dental infections
Organic nasal obstruction by deviated septum, polyps, etc.
Recent insertion of foreign object into the nasopharynx, e.g. nasal packing, NG tube
Sinus surgery
Smoking
Symptoms lasting 10 days or more: Likelihood of bacterial infection is 60%
Treatment with antibiotics per Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 suppl):S1–S39.
Treatment failure is defined as either
No improvement in symptoms 7 days after starting antibiotics
Acute symptoms worsening during treatment course
Chronic
Pt with h/o poorly controlled asthma, sarcoidosis, and cystic fibrosis presents with bilateral facial pain/pressure and nasal obstruction for > 12 consecutive weeks. Reports nasal drainage, hyposmia/anosmia during that time. Denies fever, headache, phono/photophobia, decreased/double vision, painful eye movements, orbital swelling, nuchal rigidity. Mucopurulent drainage, edema, and middle meatus polyps on exam. No periorbital swelling noted.
CT sinus without contrast shows evidence of chronic rhinosinusitis
Treatment
First line
Nasal irrigation with 240 mL isotonic saline daily
Nasal corticosteroid: Fluticasone propionate 50 mcg two sprays in each nostril once daily
Acute on chronic symptom exacerbation: Consider methylprednisolone 1 mg/kg with 21 day taper
Suspected acute, superimposed infection:
Start Augmentin 875 mg BID x 7 days
Augmentin allergy or initial treatment failure: Verify no h/o prolonged QT interval and start levofloxacin 500 mg qd x 10 days
Consults
Refer to ENT for
Unilateral symptoms and/or concern for malignancy
Uncertainty about findings on physical exam
Failed response to initial medical management with possible benefit from endoscopic surgery
Concern for orbital cellulitis: Refer to ophthalmology
Pt advised to contact office immediately if s/he experiences any of the following
Decreased/double vision, painful eye movements, orbital swelling concerning for orbital cellulitis
Fever, headache, phono/photophobia, nuchal rigidity concerning for meningitis
Notes
Risk factors include
Pulmonary disease, e.g. uncontrolled asthma, cystic fibrosis, etc.
Granulomatous disease/vasculitis, e.g. sarcoidosis, granulomatosis with polyangiitis
Diagnosis requires 2 of 4 cardinal symptoms for 12 consecutive weeks and objective evidence on physical exam or radiography
Cardinal symptoms: Facial pain/pressure, nasal obstruction, nasal drainage, hyposmia/anosmia
Physical exam: Mucopurulent drainage, edema, polyps in the middle meatus
Radiography
Do not refer unless 2 of 4 cardinal symptoms are present
Obtain without contrast if no concern for orbital involvement
Concern for orbital involvement: With and without contrast
Unilateral symptoms are concerning for alternate etiologies, e.g. malignancy
Unlike acute sinusitis, nasal irrigation and corticosteroids do improve symptoms in chronic sinusitis
Potential complications include superimposed periorbital/orbital cellulitis, meningitis, cavernous sinus thrombosis, epidural abscess
