RHINOSINUSITIS

Stuart Henochowicz, M.D., M.B.A., F.A.C.P.

Clinical Associate Professor
Division of Allergy, Immunology and Rheumatology
Georgetown University Medical School
Washington, D.C.

www.lafebervet.com

Coronal View in Relation to Facial Structure

Normal Sinus CT Scan through the OMU

Eyeball
Ethmoid sinus
Maxillary sinus
Nasal cavity

Nasal Polyp

www.entusa.com

Rhinosinusitis
More accurate term thansinusitis since almost always
preceded by or concomitant symptoms of rhinitis
Acute Up to 4 weeks
Subacute 4 to 12 weeks
Chronic > 12 weeks

Acute vs. Chronic Rhinosinusitis

Usually very different conditions.
Acute rhinosinusitis usually related to infection.

Chronic rhinosinusitis usually related to inflammation.

Acute Rhinosinusitis
1 billion viral URIs each year
0.5% - 2% lead to secondary bacterial infection of the
sinuses.1,2
Acute bacterial rhinosinusitis often present when
symptoms have not resolved after 10 days or worsen
after 5 to 7 days

1Gwaltney
2Berg

Clin Infect Dis 1996;23:1209

et al. Rhinology 1986;24:223-5

Diagnosis of Acute Bacterial

Rhinosinusitis
Acute clinical pattern

Symptoms >10 days and < 28 days

Objective confirmation either / or

Nasal exam documenting purulent d/c beyond the nasal

vestibule
Rhinoscopy
Endoscopy

Posterior pharyngeal drainage

CT scan Not recommended for routine

management
May be helpful in complex cases

Meltzer et al. JACI 2004;114:155

Diagnosis of Acute Rhinosinusitis:

2 major OR 1 major & 2 minor symptoms
Major
Anterior or posterior
purulent drainage
Nasal obstruction
Facial pain or pressure or
congestion
Hyposmia or anosmia
Fever (acute)

JACI 2004

Minor
Head ache
Ear pain/pressure
Halitosis
dental pain
Fatigue
Cough

Obstruction of the OMU with Associated

Acute Sinusitis

Sinusitis in the
ethmoid sinus.

Sinusitis in the
maxillary sinus.

Local Factors Predisposing to

Rhinosinusitis
Allergic rhinitis

Foreign body

URI

Trauma

Anatomic abnormalitiy:

Barotrauma

Deviated septum
Concha bullosa
Enlarged adenoids
Haller cells

Nasal polyps

Tumor

Diving, swimming
Smoke
Topical decongestant abuse
Nasal intubation

Systemic Factors Predisposing to

Rhinosinusitis
Immune deficiency

IgA deficiency
Panhypogammaglobulinemia
IgG subclass deficiency
HIV

Cystic fibrosis

Ciliary disorder
Granulomatosis with Polyangiitis (Wegeners)
Gastroesophageal reflux

Complications of Rhinosinusitis
Meningitis

Orbital cellulitis (ethmoid)

Subdural/epidural empyema (frontal)
Brain abscess (frontal)
Cavernous sinus thrombosis (sphenoid)
Osteomyelitis (frontal)
Asthma exacerbation

Treating acute rhinosinusitis: Comparing efficacy and safety of mometasone furoate nasal
spray, amoxicillin, and placebo
Eli O. Meltzer, MD, Claus Bachert, MD, PhD and Heribert Staudinger, MD
Volume 116, Issue 6, Pages 1289-1295

Copyright 2005 American Academy of Allergy, Asthma and Immunology

Fig 1

Source: Journal of Allergy and Clinical Immunology 2005; 116:1289-1295 (DOI:10.1016/j.jaci.2005.08.044 )

Copyright 2005 American Academy of Allergy, Asthma and Immunology

Antibiotics for Acute Sinusitis

Cochrane Database Review (2004) Peds
Available evidence suggest that antibiotics given for 10
days will reduce the probability of persistence in the
short to medium-term.

Cochrane Database Review (2004) Adults

Current evidence is limited but supports the use of
antibiotics for 7 to 14 days
Weigh the moderate benefits of abx treatment against
the potential for adverse effects

Acute Bacterial Rhinosinusitis:

Which antibiotic to use?
No randomized, placebo-controlled trials of antibiotic
treatment for ABRS using pre-and post-treatment sinus
aspirate culture

Antibiotics
20 to 30% of S. pneumoniae are penicillin resistant
30 to 40% of H. influenzae and 75 to 95% of M.
catarrhalis are beta-lactamase positive
When choosing abx consider
Recent abx use (within 6 weeks)
Severity of disease

Antibiotics for Acute

Rhinosinusitis
3. Amoxicillin-clavulanate rather than amoxicillin
alone is recommended as empiric antimicrobial
therapy for ABRS in children (strong, moderate).
4. Amoxicillin-clavulanate rather than amoxicillin
alone is recommended as empiric antimicrobial
therapy for ABRS in adults (weak, low).

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis

in Children and Adults-2012

IDSA Clinical Practice Guideline for Acute Bacterial

Rhinosinusitis in Children and Adults

-2012
7. Macrolides (clarithromycin and azithromycin) are not
recommended for empiric therapy due to high rates of
resistance among S. pneumoniae (30%) (strong,
moderate).

IDSA Clinical Practice Guideline for Acute Bacterial

Rhinosinusitis in Children and Adults
-2012

8. Trimethoprim-sulfamethoxazole (TMP/SMX) is not

recommended for empiric therapy because of high
rates of resistance among both S. pneumoniae and
Haemophilus influenzae (30%40%) (strong,
moderate).

IDSA Clinical Practice Guideline for Acute Bacterial

Rhinosinusitis in Children and Adults
-2012

9. Doxycycline may be used as an alternative

regimen to amoxicillin-clavulanate for initial
empiric antimicrobial therapy of ABRS in
adults

Acute Bacterial Rhinosinusitis:

Duration of Treatment
14. The recommended duration of therapy for
uncomplicated ABRS in adults is 57 days (weak, lowmoderate).
15. In children with ABRS, the longer treatment duration of
1014 days is still recommended (weak, low-moderate).
IDSA Clinical Practice Guideline for Acute Bacterial
Rhinosinusitis in Children and Adults- 2012

Shortcut to acute sinusitis micro.lnk

Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg

2004:130:1

Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1

Fig 1

Journal of Allergy and Clinical Immunology 2013; 132:1230-1232

Copyright 2013 American Academy of Allergy, Asthma & Immunology

Chronic Rhinosinusitis

Diagnosis of Chronic
Rhinosinusitis
Symptoms for > 12 weeks
Two main subtypes:
CRS without nasal polyps
CRS with nasal polyps
Strongly associated with asthma and
aspirin tolerance

Meltzer et al. JACI 2004;114:155

Clinical Pathologic
CRS without NP
Differences

CRS with NP

Asthma

Lower

Higher

ASA sensitivity

Lower

Higher

Inflammatory Infilt

Mostly PMNs

Mostly EOS

VCAM and IL5

Low

High

Mucus MCP

Mildly increased

Very High

Local IgE prod.

Little/unclear

Lot

Anti-Staph Toxin

Rare

Common (>50%)

Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998

Chronic Rhinosinusitis: Risk

Factors for Extensive Disease
80 patients with CRS
Factors
Eosinophil > 200/uL (OR=19.2, 95% CI=5.4-72.7
Asthma (OR=6.8, 95%CI=2.2-22)
Atopy (OR=4.3,95%CI=1.5-12.8)
Age>50 (OR=6.5,95%CI=2.0-22.2)

Hoover GE et al. JACI 1997;100:185-91

Prevalence of Allergy in CRS

Chart review of 113 sinus surgery patients
48 patients included in the study
Allergy testing by RAST or skin testing
57.4% had a positive allergy test

Guman et al. Otolaryngol Head Neck Surg 2004;130:545

Type of Allergy Among Sinus

Surgery Patients
Seasonal

Perennial

None

Perennial and
seasonal
Emmanuel et al. Otolaryngol H&N Surg 2000; 123:687 and Ramandan et al. Am J Rhinol 1999;
13:345

Diagnosis of CRS
Physical examination
Endoscopy or anterior rhinoscopy
Purulent drainage
Edema or erythema of the middle meatus or ethmoid bulla
polyps

Sinus CT scan
Mucosal thickening
Air-fluid level

Meltzer et al. JACI 2004;114:155

Medical Management of Chronic

Rhinosinusitis
Antibiotics
Corticosteroids
Decongestants
Muco-evacuants
Antihistamines

Non-pharmacologic treatment
v

Microbiology of Chronic
Rhinosinusitis
Not well defined because of differences in culturing
techniques, prior use of abx

S. pneumoniae, H. influenzae, M. catarrhalis

S. Aureus, coagulase negative staph, anaerobes
Fungi

Meltzer et al. JACI 2004;114:155

Chronic Rhinosinusitis:
Which Antibiotic to Use?

-No antibiotic is approved by FDA for CRS

-We use similar abx as ABRS

Antibiotics for Chronic

Rhinosinusitis
Appropriate duration is not well defined
AAAAI and ACAAI Joint Task Force
treat for 3,4 or 6 weeks
continue abx for at least 1 week after the patient is
symptom free

Task Force on Rhinosinusitis of the American

Academy of Otolaryngology-Head and Neck
Surgery
treat 4 to 6 weeks

Adjunctive Therapy
Decongestants
Used as adjuvant treatment
no controlled studies

Mucolytic treatment
1 double blinded study
2400 mg of guaifenesin or placebo in HIV+ with chronic
sinusitis
improvement in congestion and thick secretions

Wawrose et al. Laryngoscope 1992;102:1225

Adjunctive Therapy
Antihistamines
play a role in allergic rhinitis patients with sinusitis
Saline irrigation
may help mucociliary clearance
mild vasoconstrictor of nasal blood flow
Intravenous immune globulin
indicated in patients with impaired humoral
immunity

Surgery for Rhinosinusitis

FESS
enlarge sinus ostia
correct anatomic deformities (septal deviation, concha
bullosa)
create a common cavity for nasal drainage
ventilate sinuses
>85% improvement in selected series

Summary
Acute rhinosinusitis is usually related to infection
Antibiotic management is first line

Chronic rhinosinusitis is usually related to

inflammation
Further characterization of the condition is
important (nasal polyps)
Exploration of underlying allergy is important
Management is challenging