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(idsa 36) cnnmsor 9) Cus luS 91599) LyParanasal sinus anatomy Frontal - siays 2 ____— Sphenoid sinus Ethmoid sinuses (anterior) Maxillary sinus Schematic drawing showing location of the frontal, ethmoid, maxillary, and sphenoid sinuses. Graphic 78790 Version 6.0 © 2016 UpToDate, Inc. All rights reserved.Suggested approach to observation versus antimicrobial therapy for outpatient treatment of uncomplicated acute bacterial rhinosinusitis (ABRS) in immunocompetent adults Uncomplicated ABRS * Good follow-up? 1 Yes No Observation and symptomatic management for 7 days Improved symptoms Unchanged symptoms Worsening symptoms Option to either4: ® Observe with symptomatic management for additional 10 days or ® Initiate antibiotics Observation and symptomatic management for an additional 10 days Improved Unchanged or symptoms worsening symptoms No further evaluation needed Initiate antibiotic therapy * Uncomplicated ABRS is ABRS without evidence of extension of infection beyond the paranasal sinuses and nasal cavity into the central nervous system, orbit, or surrounding tissues. {| Good follow-up: Assurance that antibiotic therapy can be started if symptoms worsen or if no improvement within 7 days. A Decision will depend on patient presentation, comorbidities, and social factors. Refer to the UpToDate topic on treatment of uncomplicated acute sinusitis and rhinosinusitis in adults for details. Graphic 106157 Version 1.0 © 2016 UpToDate, Inc. All rights reserved.Suggested approach to empiric antimicrobial therapy for outpatient treatment of uncomplicated acute bacterial rhinosinusitis (ABRS) in immunocompetent adults Patient with uncomplicated ABRS requires antibiotics * One of the following: ® Doxycycline 100 mg twice daily or 200 mg daily or ® Levofloxacin 500 mg daily or moxifloxacin 400 mg daily or ® In patients who can tolerate cephalosporins 1 - Clindamycin 150 mg or 300 mg every 6 hours plus a third-generation oral cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) Amoxicillin-davulanate (standard dose): = 500 mg/125 mg three times daily or ® 875 mg/125 mg twice daily Amoxicillin-clavulanate (high dose) 2000 mg/125 mg twice daily Symptomatic worsening or no improvement in 7 days Treat for 5 to 7 days total Confirm the diagnosis of ABRS® No v Treat alternative diagnosis 5 Improved Symptomatic worsening or symptoms no improvement in 7 days ae fr aif * Indications for antibiotic therapy include lack of adequate follow-up, worsening symptoms during observation, and symptoms unchanged after 7 days of observation. Refer to the UpToDate topic on treatment of uncomplicated acute sinusitis and rhinosinusitis in adults for details. 4 Refer to the UpToDate topics on penicillin allergy and cephalosporin allergy. 4 Risk factors for resistance include: « Living in geographic regions with rates of penicillin-nonsusceptible S. pneumonia exceeding 10% = Age 265 years = Hospitalization in the last 5 days = Antibiotic use in the previous month = Immunocompromise = Multiple comorbidities (eg, diabetes or chronic cardiac, hepatic, or renal disease) = Severe infection (eg, evidence of systemic toxicity with temperature of 2102°F, threat of suppurative complications) 6 The diagnosis of ABRS can be confirmed clinically. In patients in whom there are concerns for complications, imaging should be obtained. In other patients in whom symptoms are not completely consistent with ABRS, imaging is reasonable to rule out sinusitis and/or evaluation for alternative diagnosis. § Refer to the UpToDate topic on treatment of uncomplicated acute sinusitis and rhinosinusitis in adults for details. ¥ Choice of second-line agent will depend on initial therapy. For patients not allergic to penicillin, options include: 1. Amoxicillin-clavulanate 2000 mg/125 mg orally twice daily 2 Levofloxacin 500 mg orally once daily 3. Moxifloxacin 400 mg orally once daily For penicillin-allergic patients options include: 1. Doxycycline 100 mg twice daily or 200 mg once daily 2 Levofloxacin 500 mg orally once daily 3. Moxifloxacin 400 mg orally once daily Graphic 106156 Version 1.0 © 2016 UpToDate, Inc. All rights reserved.Distribution of pathogens in acute bacterial rhinosinusitis Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Anaerobes Streptococcus species Other Graphic 81702 Version 2.0 © 2016 UpToDate, Inc. All rights reserved.Risk factors for resistance in patients with acute sinusitis Living in geographic regions with rates of penicillin-nonsusceptible S. pneumonia exceeding 10%* Age 265 years Hospitalization in the last five days Antibiotic use in the previous month Immunocompromise Multiple comorbidities (eg, diabetes or chronic cardiac, hepatic, or renal disease) Severe infection (eg, evidence of systemic toxicity with temperature of 2102°F, threat of suppurative complications) *Local and regional histograms of bacterial resistance should be referenced to understand resistance trends in the local community. Graphic 105611 Version 1.0 © 2016 UpToDate, Inc. All rights reserved.< Sinusitis in children ONE MONTH ONE YEAR TWO YEARS Frontal Sinus SIX YEARS / TEN YEARS ADULT SINUS ANATOMY Illustration showing the development of the sinuses from one month to adulthood. Source DynaMedLeft middle meatus with severe oedema and purulent secretions From the collection of Melissa Pynnonen, MDRight middle turbinate and middle meatus are visible after decongestant spray From the collection of Melissa Pynnonen, MDNasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus From the collection of Joseph K. HanLeft middle meatus with healthy mucosa and non- purulent secretions From the collection of Melissa Pynnonen, MDPre-op planning at a surgical navigation workstation From the personal collection of Dr Raj SindwaniImage-guided endoscopic sinus surgery using an optical-based surgical navigation system From the personal collection of Dr Raj SindwaniCase history #1 A 19-year-old woman presents with a 12-day history of purulent nasal drainage and nasal congestion, and reports a history of fever, myalgia, and facial pressure. She is otherwise healthy and works as a teacher. After 5 days of illness, the patient's symptoms started to improve; however, they have worsened in the last few days, despite the use of over-the-counter medications. Physical examination shows oedematous mucosa of the inferior turbinate. There is also thick mucus in the nasal cavity. Nasal endoscopy demonstrates purulent drainage and a small polyp in the ostiomeatal complex. The adenoids are small and erythematous. Case history #2 A 33-year-old man with a medical history of paediatric-onset asthma, atopic dermatitis, and allergic rhinitis presents with a 7-day history of facial pressure, dental pain, nasal blockage, and hyposmia. The patient developed these symptoms after recently mowing his lawn. The symptoms have not improved despite use of an intranasal corticosteroid, an antihistamine, and intranasal saline washes. Physical examination shows a septum deviated to the left side, and a large concha bullosa on the right side. There are no polyps, but there are swollen turbinates and thin, clear mucus present.< oA Acute sinusitis Prevention: Secondary prevention 9 of 25 Secondary prevention measures may be useful for patients who have recurrent acute sinusitis. Good hand washing practices (i.e., using soap or alcohol- based rubs) are recommended, especially when in contact with people who are unwell. Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible. Any underlying conditions should be assessed and treated appropriately. If recurrent episodes are due to the presence of allergies, consultation and evaluation with an otolaryngologist or allergist is considered beneficial.< oA Acute sinusitis Prevention: Primary prevention 8 of 25 Good hand washing practices (i.e., using soap or alcohol- based rubs) are recommended, especially when in contact with people who are unwell. Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible. Viral upper respiratory tract infections should be treated promptly as they can often progress to acute bacterial sinusitis. Treatment will depend on the type of infection.Types of sinusitis Duration of symptoms: [REF 2] - Acute: 4 weeks or less - Subacute: 4 to 12 weeks - Chronic: 12 weeks or more - Recurrent acute: 4 or more episodes per year. Severity: [REF 2] [REF 3] - Non-severe: absence of fever; may have mild facial or dental pain - Severe: presence of fever; moderate to severe facial or dental pain; worsening of symptoms after 3 to 5 days or no improvement by 7 days; or unilateral sinus tenderness.Basics: Definition 3 of 25 Acute sinusitis (also commonly known as acute rhinosinusitis) is a symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, where clinical symptoms have been present for 4 weeks or less. It can be caused by either a viral or a bacterial infection. [REF 1]History & examination Key diagnostic factors « symptoms <10 days (acute viral sinusitis) - symptoms >10 days but <4 weeks (acute bacterial sinusitis) « severe symptoms at onset (acute bacterial sinusitis) « symptoms that worsen after an initial improvement (acute bacterial sinusitis) « purulent nasal discharge « nasal obstruction - dental pain - facial pain/pressure Other diagnostic factors « cough - myalgia - sore throat - hyposmia - oedematous turbinate - fever