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