ACUTE RHINOSINUSITIS

I.

OBJECTIVES
a. To define rhinosinusitis and describe its epidemiology
b. To differentiate acute from chronic rhinosinusitis
c. To enumerate the different etiologies of rhinosinusitis
d. To describe the clinical presentation of rhinosinusitis
e. To discuss the appropriate antimicrobial therapy for sinusitis

II.

CASE SCENARIO
A teenage boy is brought to the clinic for two weeks severe nasal congestion, thick
yellow mucoid discharge, and undocumented fever unrelieved by over-the-counter
cold and flu medications. He had facial pain and headache for one week, worsened by
changes in head position, coughing, and straining. Inspection reveals conjunctival
injections and a hyperemic external nose. His forehead, nasal bridge, and cheeks are
warm and tender to palpation. Rhinoscopy shows congested, edematous turbinates
obstructing nasal airflow, and yielding mucopurulent material from the lateral nasal
walls on decongestion.

III.

EPIDEMIOLOGY
Sinusitis / Acute Rhinosinusitis
Refers to an inflammatory condition involving the four paired structures
surrounding the nasal cavities.
Develops when natural drainage of the paranasal sinuses is affected by nasal
inflammation or pathology.
Most cases are diagnosed in the ambulatory care setting and occur primarily
as a consequence of a preceding viral upper respiratory infection.
Typically classified by:
o Duration acute vs. chronic
o Etiology infectious vs. non-infectious
o Pathogen viral, bacterial, or fungal
Most cases involve more than one sinus.
Sinuses involved, in order of frequency:
o Maxillary
o Ethmoid
o Frontal
o Sphenoid
Vicious cycle resulting to rhinosinusitis:
o Altered mucociliary clearance
o Retained secretions
o Ostiomeatal unit obstruction
Sinusitis affects a tremendous proportion of the population, accounts for
millions of visits to primary care physicians each year, and is the fifth leading
diagnosis for which antibiotics are prescribed.

IV.

PHYSICAL EXAMINATION OF THE PARANASAL SINUSES

Presentation of a patient with acute rhinosinusitis:
o In obvious pain
o Guard against jarring movements
1

V.

o Nasal decongestion yields purulent discharge from the ostiomeatal

area lateral to the middle turbinate.
o Orbital complications (preseptal, septal, or orbital)
Presentation of a patient with chronic rhinosinusitis:
o May appear normal
o Woakess syndrome suggests massive nasal polyposis:
Widening of the nasal bridge
Hypertelorism
Epiphora
Sinus palpation is performed by:
o Percussion
o Pressing firmly but gently over the most accessible points of maximum
tenderness for each sinus:
Sphenoid vertex
Frontal superomedial roofs of the orbital sockets
Ethmoid nasal bones between medial canthi
Maxillary incisive fossae of cheeks superolateral to canine
roots
Upper jaw teeth (especially canines) may be tender when tapped gently in
cases of acute maxillary sinusitis.
Sinus tenderness may be elicited by asking the patient to jump (positive jump
test).
Warrant urgent specialist referral:
o Swelling
o Masses
o Infraorbital nerve hyposthesia
o Extraocular muscle motion limitations

ETIOLOGY
Non-infectious causes:
o Allergic rhinitis with either mucosal edema or polyp obstruction
o Barotraumas from deep-sea diving or air travel
o Exposure to chemical irritants
o Nasal and sinus tumors squamous cell carcinoma
o Granulomatous diseases Wegeners or rhinoscleroma
o Conditions leading to altered mucus content through impaired mucus
clearance cystic fibrosis
Major risk factors for nosocomial sinusitis
o Nasotracheal intubation
o Nasogastric tubes
Viral rhinosinusitis is far more common than bacterial sinusitis
o Most commonly isolated:
Rhinovirus
Parainfluenza virus
Influenza virus
Bacterial causes of sinusitis have been better described.
o Community-acquired
Streptococcus pneumoniae and Haemophilus influenzae
Most common pathogens; 50 60% of cases
2

VI.

Moraxella catarrhalis 20%

Other streptococcal species
Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus emerging
Anaerobes
o Nosocomial infections are usually polymicrobial:
Staphylococcus aureus
Pseudomonas aeruginosa
Serratia marcescens
Kelbsiella pneumoniae
Enterobacter spp.
Fungi are also established causes of sinusitis, although most acute cases are in
immunocompromised patients and represent invasive, life-threatening
infections. These infections classically occur in diabetic patients with
ketoacidosis but also can develop in transplant recipients, patients with
hematologic malignancies, and patients receiving chronic glucocorticoid or
deferoxamine therapy. The best known example is rhinocerebral
mucormycosis caused by fungi of the order Mucorales, which includes:
o Rhizopus
o Rhizomucor
o Mucor
o Mycocladus
o Cunninghamella
Other hyaline molds, such as Aspergillus and Fusarium species, are also
occasional causes.

ACUTE RHINOSINUSITIS (ARS)

Comprises of:
o Viral ARS (common cold)
Symptoms for less than 10 days
o Post-viral ARS
Symptoms that increase after five days or persist after 10 days
A very common condition that is primarily managed in primary care
Prevalence rates: vary from 6% - 15%
Acute bacterial rhinosinusitis (ABRS)
o Highly likely when upper respiratory symptoms have been present
without any clinical improvement for at least seven to 10 days having
at least three of the following symptoms or signs:
Discolored purulent nasal discharge (especially with unilateral
predominance)
Severe facial, sinus, or local pain (especially if aggravated by
postural changes or Valsalva maneuver)
Fever (> 39 C)
Double sickening deterioration after an initial milder phase
of illness
o European Position Paper (EPOS 2012) includes the following criteria
for ABRS:
Lower threshold for fever (>38 C)
Elevated ESR/CRP
3

VII.

Best predictors of ABRS:

o Maxillary toothache or tooth pain not of dental origin
o Poor response to decongestants
o Patients reports of colored nasal discharge
o Purulent secretions by exam
ABRS in children:
o Presence of a constellation of signs and symptoms of at least 10 days
duration without improvement.
There is no room for imaging studies or further tests to establish a diagnosis of
ARS or ABRS in adults or children.

TREATMENT OPTIONS FOR ACUTE RHINOSINUSITIS

Antibiotics are not useful for viral and mild, moderate, or uncomplicated postviral ARS. Many clinical studies have proven that such ARS resolves without
antibiotics in most cases, with symptoms clearing in up to 70% without
antibiotics within two weeks.
Empiric antimicrobial therapy should be initiated as soon as the diagnosis of
ABRS is made, targeting the most likely pathogens.
o Streptococcus pneumoniae
o Haemophilus influenzae
Amoxicillin (40 mg/kg/day or 80 mg/kg/day in children) is the first-line
antibiotic of choice.
Amoxicillin-clavulanate rather than amoxicillin alone is recommended as
first-line empiric antimicrobial therapy in both children and adults by the
Infectious Diseases Society of America.
In the local setting, amoxicillin should be a reasonable first-line antibiotic that
can be shifted to amoxicillin-clavulanate if there is no response in 48 72
hours.
A 10-day course has been shown to achieve bacteriologic cure.
High-dose, twice-daily oral amoxicillin-clavulanate (90 mg/kg/day in children
or 2 g in adults) is recommended for the following patients:
o In areas highly endemic for invasive penicillin-nonsusceptible
Streptococcus pneumoniae
o With severe infection, threat of suppurative complications, attendance
at daycare, recent hospitalization, or antibiotic use within the past
month
o Age < 2 or > 65 years
o Immunocompromised
Second-line agents:
o For those with hypersensitivity to penicillin:
Doxcycycline
Levofloxacin
Moxifloxacin
Macrolides
Quinolones not recommended
o For children without a type I hypersensitivity to penicillin:
Combination therapy with clindamycin and a third-generation
oral cephalosporin (cefixime or cefpodoxime)
Trimethoprim-sulfamethoxasole
4

Azithromycin
Clarithromycin
o US FDA-approved drugs for the treatment of acute sinusitis:
Cefuroxime, cefpodoxime
Clarithromycin, azithromycin
Levofloxacin
Antibiotic treatment should be started earlier (before 7 days) for patients
with:
o Anatomical blockage nasal polyps, severe septal deviation
o Recurrent sinusitis
Patients with severe symptoms requiring emergent care:
o Visual disturbances
o Orbital pain
o Periorbital swelling or erythema
o Facial swelling or erythema
o Signs of meningitis or cavernous sinus thrombosis (worst headache of
my life)
Intranasal corticosteroids
o Recommended as twice-daily monotherapy for moderate ARS
o In combination with oral antibiotics for severe ABRS
Antihistamines are only indicated in the presence of underlying allergic
rhinitis.
Adjunctive therapy:
o Topical congestants
Have efficacy in symptom control
Decongest the inferior and middle turbinates and infundibular
mucosa
Have anti-inflammatory and anti-oxidant effects
Improve mucociliary transport
o Physiologic or hypertonic intranasal saline irrigation has a limited
effect on adults with ARS
All patients treated for ABRS should be reevaluated before the 10-day
antibiotic course ends, and those with persistence after seven days or
worsening disease after three to five days should be evaluated by an ENT
specialist.

VIII. IMAGING MODALITIES

Paranaasal sinus (PNS) computed tomography (CT) scan
o Imaging modality of choice for persistent, recurrent or chronic
sinusitis, or surgical preparation
Plain sinus x-rays
o Least appropriate imaging modality
Cranial/orbit CT with contrast
o For suspected orbital or cranial complications of ABRS
CT and MRI are complementary for evaluating cranial and orbital
complications such as orbital or epidural abscess and cavernous sinus spread.

IX.

CHRONIC SINUSITIS AND CHRONIC RHINOSINUSITIS

May be associated with chronic rhinitis or remain largely asymptomatic,
presenting only with post-nasal drip or chronic cough
A condition that lasts from a low cut-off of more than 4 weeks to a high cutoff of more than 12 weeks
Subdivisions of chronic rhinosinusitis (CRS):
o CRS with nasal polyps (CRSwNP)
o CRS without nasal polyps (CRSsNP)
Diagnosis usually involves nasal and sinus endoscopy.
Paranasal sinus CT scans are indicated for patients who do not respond to
therapy of acute rhinitis or sinusitis.
Structural problems obstructing sinus drainage, benign, premalignant, and
frankly malignant conditions must be ruled out and managed appropriately by
a specialist.

X.

CHRONIC RHINOSINUSITIS WITH NASAL POLYPS

Nasal polyps
o Semi-translucent, smooth-surfaced, gelatinous masses arising from
nasal and sinus mucosa
o Do not shrink with decongestion
o Non-sensate on palpation
o May cause nasal obstruction, rhinorrhea, sneezing, and pain.
Both intranasal and systemic corticosteroids are effective for the management
of CRSwNP.

XI.

CASE RESOLUTION
The teenage boy had severe acute bacterial rhinosinusitis without nasal polyposis that
persisted despite twice-daily oxymetazoline 0.05% nasal decongestion, saline
douches, and thrice-daily high-dose amoxicillin. A shift to co-amoxiclav after two
days improved his condition which resolved in a week. Antibiotics were continued
for another week, with a final evaluation scheduled before the completion of the full
course of treatment.