Chapter 28: Acute Rhinosinusitis

Definition and Diagnostic Criteria

• Acute rhinosinusitis (ARS): sinonasal inflammation lasting less than 4 weeks with sudden onset of symptoms

• Symptoms: nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior) and facial pain/pressure or reduction/loss of smell

Classification

• Acute viral rhinosinusitis (AVRS)

  1. Symptoms or signs present less than 10 days and without worsening of symptoms

• Acute bacterial rhinosinusitis (ABRS)

  1. Persistent symptoms beyond 10 days or worsening of symptoms after 5 days indicated postviral ABRS (double-sickening).

  2. Haemophilus influenza, Streptococcus pneumonia, Moraxella catarrhalis are the most common bacteria in both adults and children.

• Recurrent ARS (RARS): Four or more episodes of ARS with symptom-free intervals between episodes.

Pathophysiology

• Allergy, environmental irritants, and microbes cause mucosal swelling and sinus ostial obstruction

• Anatomic abnormalities block natural drainage pathways: septal deviation/spur, middle turbinate concha bullosa, prominent agger nasi cell or frontal cells, Haller cells

• Viruses: AVRS inhibits mucociliary clearance and precedes ABRS

• Allergic rhinitis with systemic IgE-mediated response

• Odontogenic infections

Diagnostic evaluation

• Based on clinical symptoms according to diagnostic criteria

• Anterior rhinoscopy recommended; nasal endoscopy and imaging not required for uncomplicated cases

• Differential diagnosis: Allergic rhinitis, dental disease, chronic fatigue syndrome, facial pain syndromes

Treatment of ARS

• Goals of treatment

  1. Decrease time of recovery

  2. Prevent chronic disease

  3. Decrease exacerbations of comorbidities (ie, asthma)

  4. Reestablish patency of osteomeatal complex

  5. Reduce inflammation and restore drainage of infected sinuses

  6. Eradicate bacterial infection and minimize risk of complications

• Medical treatment of ARS

  1. Symptomatic relief

     • Strong recommendation for topical intranasal steroids first line, which improve symptoms and hasten recovery

     • Nasal saline irrigation is an option

  2. Antibiotic therapy

     • Therapy offers potential for shorter duration of symptoms and reduced pathogen carriage

     • With mild or uncomplicated disease, offer observation if follow-up is ensured. Otherwise, can offer initial antibiotic therapy.

     • With moderate to severe disease (symptoms persistent or worsening; temperature > 38°C), offer antibiotic.

     • Empiric oral antibiotic:

       • – First line: amoxicillin with or without clavulanate (has potential for GI upset, bacterial resistance)

       • – In penicillin allergic patient: doxycycline or respiratory quinolone (levofloxacin or moxifloxacin)

  3. If no improvement on initial antibiotics, prescribe alternate antibiotic and consider complications or other causes of illness

  4. Oral corticosteroids not recommended

  5. Insufficient evidence for benefit of decongestants and antihistamines

  6. Imaging usually not required unless complications suspected

• Surgical treatment of ARS:

  • Only limited to patients with complications of sinusitis (orbital or intracranial)

Pediatric Acute Rhinosinusitis

• Strong relation between viral URI and ARS

• Similar symptoms to adults (purulent nasal discharge, nasal obstruction, facial pain/pressure)

• Pediatric patients more likely to present with behavioral problems (ie, irritability) or cough, and less likely headache or fatigue

Definition

• Sudden onset of two or more of the following symptoms: nasal blockage/obstruction/congestion or discolored nasal discharge or cough (daytime and nighttime) for less than 12 weeks

• Subdivisions:

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