Sinusitis

Source: C, Frei B, Zhanel G. Upper Respiratory Tract Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8001906. Accessed July 15, 2012.

• Rhinosinusitis

• Inflammation and/or infection of paranasal sinus mucosa
  • Acute: lasts <30 days with complete resolution of symptoms.
  • Chronic: episodes of inflammation lasting >3 months with persistence of respiratory symptoms.

• Majority of cases viral
  • Consider bacterial infection if symptoms persist for ⩾7 days or become severe.
• Bacterial causes: S. pneumoniae and H. influenza
  • Responsible for ~70% of bacterial causes of acute sinusitis in both adults and children.

• Acute bacterial sinusitis usually preceded by viral respiratory tract infection that causes mucosal inflammation.

• Most cases have viral etiology yet antibiotics prescribed for adults and children.

• Viral respiratory tract infection

• Nonspecific upper respiratory tract infection that persists beyond 7–14 days

Signs and Symptoms

• Acute
  • Adults
    • Nasal discharge/congestion
    • Maxillary tooth pain, facial or sinus pain
      • May radiate (unilateral in particular)
      • Deteriorates after initial improvement
    • If severe or persists beyond 7 days, most likely bacterial and should be treated with antimicrobials.
  • Children
    • Indications for antimicrobial therapy
      • Nasal discharge and cough for >10–14 days or
      • Severe signs and symptoms such as temperature 39°C (102.2°F) or
      • Facial swelling or pain
• Chronic
  • Similar symptoms as with acute sinusitis but more nonspecific
  • Rhinorrhea with acute exacerbations
  • Chronic unproductive cough, laryngitis, and headache
  • Chronic/recurrent infections occur 3–4 times a year
    • Unresponsive to steam and decongestants.

Means of Confirmation and Diagnosis

• Gold standard: Sinus puncture with recovery of bacteria in high density
  • Not routinely performed since invasive procedure.
• Diagnosis based on clinical findings.

Laboratory Tests

• Gram stain, culture, and sensitivities of draining fluid or aspirated fluid if sinus puncture performed.

Imaging

• Sinus radiography
  • Not routinely used for uncomplicated sinusitis.

Diagnostic Procedures

• Sinus puncture

• Reduce signs and symptoms.
• Achieve and maintain patency of ostia.
• Limit antimicrobial treatment to those who may benefit.
• Eradicate bacterial infection with appropriate antimicrobial therapy.
• Minimize duration of illness.
• Prevent complications.
• Prevent progression from acute disease to chronic disease.

• Delineate viral and bacterial sinusitis.
  • Based on disease duration
    • Viral: typically improves in 7–10 days.
    • Bacterial: persistent symptoms ⩾10 days or worsening of symptoms after 5–7 days.

• Irrigation of nasal cavity with saline and steam inhalation to increase mucosal moisture
• Mucolytics (e.g., guaifenesin) to decrease viscosity of nasal secretions
• Nasal decongestant sprays such as phenylephrine and oxymetazoline
  • Reduce inflammation by vasoconstriction
  • Limit use to no more than 3 days to prevent rebound congestion.
• Oral decongestants may also aid in nasal or sinus patency.
• Avoid use of antihistamines.

• Amoxicillin first-line treatment for acute bacterial sinusitis. Approach to treating acute bacterial sinusitis in Table 1. Dosing guidelines in Table 2.
  • Treat for 10–14 days, or at least 7 days after signs and symptoms under control.