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Medical Management of Sinusitis

last modified on: Tue, 03/12/2024 - 13:28

return to: Paranasal Sinus Surgery Protocols

see also: Intranasal medications (steroid nasal spray, antihistamine nasal spray, nasal irrigations)

Note: Last updated before 2013

updating: xylitol; dupixent; nucala

DIAGNOSIS

  1. Sinusitis may be clinically defined as the condition manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and the underlying bone.
  2. The United States Food and Drug Administration (FDA) recognizes "acute rhinosinusitis" as a condition lasting up to four weeks and "chronic rhinosinusitis" as a condition diagnosed after three months of rhinosinusitis. "Subacute rhinosinusitis" may be taken to refer to the time period in between.
    1. See Classification (Lanza 1997) 
    2. Chronic adult rhinosinusitis (Lanza 1997)
      1. Major Factors
        1. Facial pain/pressure
        2. Facial congestion/fullness
        3. Nasal obstruction/blockage
        4. Nasal discharge/purulence/discolored postnasal drainage
        5. Hyposmia/anosmia
        6. Purulence in nasal cavity on examination
        7. Fever (acute rhinosinusitis only)
      2. Minor Factors
        1. Headache
        2. Fever (all nonacute)
        3. Halitosis
        4. Fatigue
        5. Dental pain
        6. Cough
        7. Ear pain/pressure/fullness
      3. A history indicative of chronic rhinosinusitis includes two or more "major" factors or one major and two minor factors.
      4. A history of facial pain alone is not, in and of itself, highly suggestive of chronic rhinosinusitis.
      5. To be diagnosed as chronic, symptoms consistent with the diagnosis must persist for 12 or more weeks.
    3. Acute adult rhinosinusitis
      1. Sudden in onset and self-limiting
      2. Most acute infections are viral in origin.  Less than 2% of viral rhinosinusitis is due to a bacterial origin.  Infections that do not improve after 10 days or worsen after 5-7 days may be bacterial.
      3. May last up to four weeks
      4. A strong history indicative of acute sinusitis includes two or more major factors from Table IIA-2 or one major and two minor factors. In the absence of other supporting symptoms, fever or pain alone is not indicative.
      5. Acute rhinosinusitis can be differentiated from a simple upper respiratory tract infection, in part by the longevity and/or severity of symptoms.

EXAMINATION

  1. An appropriate examination encompasses the head and neck, including otoscopy, anterior rhinoscopy, oropharyngoscopy, and neck examination.
  2. Most patients with acute sinusitis do not require nasal endoscopy.
  3. In suspected chronic sinusitis, nasal endoscopy may reveal localized purulent drainage or predisposing factors, such as nasal polyps, septal deviations, scar bands, postoperative changes, or generally swollen mucosa.
  4. Symptoms and signs of involvement of adjacent structures, such as the eye, brain, or skin of the face or forehead, suggest a complication of sinusitis.

NASAL ENDOSCOPY

  1. Nasal endoscopy is indicated for investigation of persistent rhinologic symptoms.
  2. A 4 mm 0 or 30 degree rigid telescope provides a good overall view of the nasal cavity and nasopharynx. The nose may be sprayed with a topical anesthetic and decongestant. Endoscopy may be performed without these sprays in order to visualize the nasal cavity in its natural state without decongestants with care taken to avoid touching the nasal septum and floor of nose to avoid discomfort.   The endoscope is first passed below the inferior turbinate back toward the nasopharynx.  Next the scope with withdrawn anteriorly and a pass will next be made to visualize the middle turbinate and middle meatus. Endoscopy may reveal septal deviations, polyps, masses, synechiae, or other changes from previous surgery or infection.
  3. Endoscopic-directed cultures from the middle meatus using Calgi-Swabs® may provide useful microbiological information in chronic disease.
  4. In patients who are immunocompromised and suspected of having fulminant invasive fungal rhinosinusitis, the middle turbinates are assessed endoscopically and may provide the first clue to diagnosis.

IMAGING STUDIES

  1. Uncomplicated acute rhinosinusitis requires no imaging studies.
  2. Imaging studies are reserved for cases of complicated sinusitis and selected cases of chronic sinusitis, unresponsive to initial treatment.
  3. Plain sinus films have been almost entirely superseded in our practice by other imaging modalities. Occasionally, a single Waters view can be used to follow the course of isolated antral opacity. A nonmagnified view of the frontal sinus can be used as a surgical template for osteoplastic frontal sinus surgery.
  4. Limited-cut CT scans can be used in initial diagnosis of chronic sinusitis and as a means of following the condition. They are not suitable for preoperative planning.
  5. The "gold standard" for imaging the paranasal sinuses is a fine-cut coronal CT scan. Axial views are of use in the frontal and sphenoid sinuses, and sagittal reconstructions have particular utility in imaging of the frontal sinus.
  6. CT scans are performed after a trial of maximal medical therapy. It is our practice to obtain these scans eight weeks after starting maximal medical therapy.
  7. Our only exception to this rule is in patients with recurring episodes of acute disease that has been diagnosed as sinusitis and in whom nasal endoscopy is noncontributory. A CT scan performed while these patients are maximally symptomatic will reveal whether their diagnosis is in fact sinusitis.
  8. Patients whose CT scans demonstrate paranasal sinus opacity adjacent to a skull-base defect require an MRI scan to exclude such processes as encephalocele and vascular abnormalities related to the carotid.
  9. Thin cut axial CT scans may be obtained for use with computer image guidance systems during surgery.  These should be ordered with "stealth" protocol or according to the protocol developed with the radiology department and the manufacturer of the computer image guidance system.  The computer image guidance system will then reconstruct the images in coronal and sagittal planes.  The tip of the nose should be included in the scan for registration purposes.

TREATMENT

  1. Acute Rhinosinusitis
    1. Acute rhinosinusitis is a self-limiting condition. A course of an antibiotic may decrease the length of symptoms.  Antibiotics are not recommended for acute cases of viral rhinosinusitis.  Antibiotics may be appropriate for cases of acute bacterial rhinosinusitis with symptoms present for 10 days after viral upper airway infection or worsening of symptoms after 5-7 days. We use amoxicillin 500mg TID in nonallergic patients for 10 days. In all patients, the use of the antibiotic must be weighed against various concerns, for example, antibiotic-induced diarrhea. All patients given antibiotics are counseled to stop the antibiotic if significant diarrhea or abdominal upset develops. They are further instructed to take acidophilus tablets or yogurt with active cultures to favorably influence intestinal flora. Individual patients may find over-the-counter medications symptomatically helpful.
  2. Recurrent Acute Sinusitis
    1. In addition to treatment of acute episodes of sinusitis, a search is made for predisposing factors. A combination of nasal endoscopy and CT scans may demonstrate anatomical predisposing factors, such as nasal polyps, septal deviation, concha bullosa, or infraorbital ethmoid cells (Haller cells). Allergy evaluation may be of benefit to some patients.
  3. Chronic Sinusitis
    1. Antibiotic selection in cases of chronic sinusitis will depend upon previous antibiotics used and previous duration of treatment. In patients who have had little by way of previous treatment, amoxicillin is employed for three weeks in doses of 500 mg TID in patients not allergic to penicillin.
    2. For patients who have received previous courses of treatment, a culture-directed antibiotic is employed for three to four weeks. The culture is taken from the middle meati using Calgi-Swabs® under endoscopic guidance. When no material is readily culturable, an empiric choice of broad-spectrum antibiotic is made. Antibiotics commonly used are:
      1. Clarithromycin, 500mg, BID
      2. Clindamycin, 300mg, QID
      3. Levofloxacin, 500 mg, QD
      4. Amoxicillin/clavulanate potassium, 875mg, BID
    3. Patients with chronic sinusitis usually benefit from a steroid nasal spray. Many will also benefit from nasal saline irrigations. The "recipe" for the irrigations and patient instructions are listed in Nursing Protocols (Home Care Instructions, Nasal Irrigation).
    4. Patients with symptoms suggestive of allergies are referred for an evaluation by an allergist. They may benefit from antihistamine use, sodium cromoglycate (Cromolyn) nasal spray, testing for specific allergens, and eventual immunotherapy.
    5. Patients with severe, recurrent, or unusual infections may be immunocompromised and benefit from an immune-deficiency workup. Occasionally patients, particularly in the younger age groups, may first be diagnosed with cystic fibrosis as a result of paranasal sinus manifestations with polyposis. When cystic fibrosis is suspected, a sweat-chloride test and genetic analysis can be performed.
    6. Surgery is not considered in patients with chronic sinusitis until they have failed two prolonged courses of broad-spectrum antibiotics. In these circumstances, the patient must feel that their symptoms are sufficiently bothersome to warrant surgery. A full and frank discussion of the risks, benefits, and alternatives to operative intervention is carried out.
  4. Fungal Sinusitis
    1. Treatment of fungal sinusitis depends on accurate diagnosis of the type of fungal sinusitis. The four varieties of fungal sinusitis are acute fulminant invasive, chronic indolent, fungal ball, and allergic fungal sinusitis. Each has different prognoses and treatments.
    2. Fulminant invasive fungal sinusitis is almost always seen in the context of an immunocompromised patient (eg. bone marrow transplant or diabetic patient). The patient's prognosis often reflects the cause, degree, and reversibility of the immunocompromise. The mainstays of treatment are surgery with resection to normally bleeding tissue and antifungal drugs, of which amphotericin-B is most commonly used. Granulocyte colony-stimulating factor and hyperbaric oxygen are occasionally used.
    3. Chronic indolent fungal sinusitis is extremely uncommon in the United States.
    4. Fungal balls can be treated by surgical evacuation of the fungus and aeration of the sinus.
    5. Allergic fungal sinusitis is a complex, incompletely understood disease. Initial treatment involves surgical removal of the fungus and use of systemic steroids. The duration of treatment, dosing, and assessment of response to the systemic steroids is controversial. Equally controversial is the role of oral antifungal agents postoperatively such as itraconazole. Immunotherapy may be of help in the postoperative period. All patients are placed on nasal saline irrigations and topical steroid sprays.

COMPLICATIONS

  1. Orbital
    1. Chandler classification
      1. Periorbital (preseptal) cellulitis: infection anterior to orbital septum
      2. Orbital cellulitis: infection posterior to orbital septum
      3. Subperiosteal abscess: collection of pus between bone and periosteum
      4. Orbital abscess: collection of pus in orbital soft tissues
      5. Cavernous sinus thrombosis
  2. Intracranial
    1. Epidural abscess
    2. Subdural abscess
    3. Brain abscess
    4. Meningitis

REFERENCES

Graham SM, Ballas ZK. Preoperative steroids confuse the diagnosis of allergic fungal sinusitis. J Allergy Clin Immunol. 1998;101:139-140.

Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surgery. 1997;117(Suppl 3, Part 2)51-57.

AnonJB, Jacobs MR, Poole MD, Ambrose PG, Benninger MS, Hadley JA, Craig WA; Sinus And Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis.  Otolaryngol Head Neck Surg 2004 Jan;130(1 Suppl):1-45.