Acute and Chronic Rhinosinusitis Flashcards
In the past decade, the term rhinosinusitis has
been commonly used to describe what condition?
Inflammation of the nose and paranasal sinuses. This term
is preferred over sinusitis because sinusitis almost always
involves the nasal cavity.
According to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007), what
are the criteria for diagnosing rhinosinusitis?
Inflammation of the paranasal sinuses, with two or more of
the following:
● Nasal blockage, obstruction, congestion, or nasal dis-
charge (anterior and/or posterior)
● ± Facial pain or pressure
● ± Hyposmia or anosmia
Describe the five major classifications of
rhinosinusitis based on symptom time course.
● Acute: < 4 weeks with complete resolution
● Recurrent Acute: Four or more episodes per year lasting ≥ 7
to 10 days; complete resolution between episodes
● Subacute: 4 to 12 weeks; controversial designation
(considered as a “filler term”)
● Chronic (± NP): > 12 weeks, without complete resolution
● Acute exacerbations of CRS: Worsening from baseline
chronic symptoms, followed by return to baseline
What is one of the tools used to assess the
severity of rhinosinusitis symptoms?
● 10-cm visual analog scale: “How troublesome are your
symptoms of rhinosinusitis?”
● Range: 0 = Not troublesome, 10 = Worst thinkable
● 0 to 3 = Mild
● 3 to 7 = Moderate
● 7 to 10 = Severe
Define double worsening/sickening.
Symptoms that worsen following initial improvement
What type of acute rhinosinusitis occurs two to five times per year in the average adult, has a
symptom peak at 2 to 3 days, progressively
improves after day 5, and has symptom resolution
by day 10 to 14?
Acute viral rhinosinusitis
What are the two most common pathogens associated with acute viral rhinosinusitis?
Rhinovirus and Influenza virus
What percentage of viral rhinosinusitis is estimated
to progress to bacterial sinusitis?
0.5 to 2%
What type of acute rhinosinusitis lasts for > 10 days or manifests with worsening of symptoms after day 5?
Acute bacterial rhinosinusitis (ABRS)
In addition to the diagnostic symptoms associated
with rhinosinusitis, what secondary symptoms may
suggest ABRS?
Fever, aural fullness, cough, myalgias, or headache
What pathogens are most commonly involved in
ABRS?
● Streptococcus pneumoniae (30%)
● Haemophilus influenzae (20 to 30%)
● Moraxella catarrhalis (10 to 20%)
What workup is recommended for acute
rhinosinusitis?
● Not recommended: CT or X-ray
● CT may be considered for severe disease, immunocom-
promised patients, clinically suspicious complications,
preoperative evaluation, or evaluation of recurrent acute
rhinosinusitis.
Optional
● Anterior rhinoscopy
● Nasal endoscopy: Consider for initial workup, if disease is
refractory to empiric treatment, for unilateral disease,
when symptoms are severe or disabling
● Nasal culture: Treatment failure, complications
When should you consider a sinus puncture using
a large-bore needle through the canine fossa or inferior meatus for workup of acute rhinosinusitis?
● Clinical trials: Standard for identifying bacterial pathogens
in the maxillary sinuses
● Potentially useful if episodes are refractory to treatment
or when rapid diagnosis and identification of pathogens
are required (e.g., in an immunocompromised patient)
According to the European Position (EPOS) Paper
on Rhinosinusitis and Nasal Polyposis (2007) and supported by data in EPOS 2012, what treatment strategy should be used for mild acute rhinosinusitis with symptoms lasting < 5 days or improving after 5 days?
Symptomatic treatment
● Decongestant
● Saline irrigation
● Analgesics
Why do some guidelines on acute rhinosinusitis
recommend against using mucus color to dictate
antibiotic use?
Mucus color is driven by neutrophils, not bacteria.
If a patient has moderate to severe symptoms of
acute rhinosinusitis that persist or worsen after 5
days, what is the recommended treatment
according to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007) and
supported by data in EPOS 2012?
Initiate intranasal corticosteroids. If no improvement is seen
after 14 days → reconsider diagnosis, perform nasal endoscopy, consider an intranasal culture, and consider imaging. Also consider antibiotics, if indicated, if no improvement has occurred after 14 days.
For a patient with acute rhinosinusitis with a
temperature > 38oC or in severe pain, what
treatment is recommended?
● Intranasal corticosteroids
● Antibiotics
● May consider an oral steroid to decrease pain
● Symptomatic management (i.e., analgesia)
Note: Improvement is expected within 48 to 72 hours.
When should an antihistamine be used in the treatment of patients with acute rhinosinusitis?
Use antihistamines only in patients with a history of allergic rhinitis or allergic disease.
Although decongestants can benefit patients with
rhinosinusitis by decreasing mucosal swelling and
potentially relieving paranasal sinus outflow obstruction, there is no conclusive published evidence for their use in this disease. What is the maximum amount of time they should be used for?
5 days
The Infectious Disease Society of America’s (IDSA) 2012 Guidelines for ABRS in children and adults recommends initiating antibiotic therapy for what signs and symptoms?
● Persistent signs or symptoms of ABRS for ≥ 10 days
● Severe signs or symptoms for ≥ 3 to 4 days (temper-
ature ≥ 39oC, 102oF; purulent nasal discharge, facial pain at the beginning of illness, or other concerning findings suggestive of complicated ABRS)
● Worsening or double sickening at ≥ 3 to 4 days
In the IDSA’s algorithm, once a patient meets the
criteria to receive an antibiotic, the risk for
resistance must be assessed. What makes a patient
high risk?
● Age < 2 years or > 65 years
● Attends daycare
● Antibiotics taken within the past month
● Hospitalization within the past 5 days
● Immunocompromised status
● Other comorbidities such as asthma, cystic fibrosis, etc.
● Geographic region with high endemic rates of penicillin-
resistant Streptococcus pneumoniae (> 10%)
If a patient meets the criteria for an antibiotic
and is not considered at high risk for resistance,
what is the first-line antibiotic recommended by the IDSA?
Standard-dose augmentin for 5 to 7 days (adults)
These guidelines recommend against the use of amoxicillin
because of concern about an increasing number of patients
developing ABRS from Haemophilus influenza since the
introduction of pneumococcal conjugate vaccines as well as increasing β-lactamase production in these strains. However, previous guidelines published in the otolaryngology literature suggest amoxicillin as first line.
If a patient meets the criteria for an antibiotic
and is considered at high risk for resistance, what
is the second-line antibiotic recommended by the
IDSA?
● High-dose amoxicillin-clavulanate (amoxicillin dosed at
2 g twice daily or 90 mg/kg daily given twice daily) for 7
to 10 days
● Doxycycline
● Levofloxacin/moxifloxacin
In penicillin allergic patients, what antibiotics are recommended by the IDSA for adults?
● Doxycycline ● Levofloxacin ● Moxifloxacin ● Cefixime/cefpodoxime and Clindamycin Not macrolides or trimethoprim-sulfamethoxazole because of concern for resistance
According to the IDSA, for a patient being treated
with either a first- or second-line antibiotic for
acute bacterial rhinosinusitis (who does not
demonstrate symptomatic improvement or presents
with worsening symptoms after 3 to 5 days of
treatment), is switched to a different class of
antibiotic or broader coverage, and again demon-
strates no improvement or worsening after 3 to 5
days, what additional steps should be considered?
● CT and/or MRI (CT preferred) to look for anatomical
problems and suppurative complications
● Sinus culture to help direct pathogen specific antimicro-
bials
● Consider referral to infectious disease or allergy specialist
(and ear, nose, and throat [ENT] specialist).
When should surgical intervention be considered
for patients with acute rhinosinusitis?
Only if complications are present that would benefit from
surgical intervention or for recurrent acute rhinosinusitis
thought to be caused by an anatomical abnormality
What criteria are required for diagnosis of CRS
according to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007 and 2012)
and the Clinical Practice Guidelines: Adult Sinusitis
(2007)?
Two or more of the following symptoms for ≥ 12 weeks:
● At least one of (1) nasal blockage/obstruction/congestion
or (2) nasal discharge (anterior or posterior, mucopur-
ulent)
● Facial pain/pressure or fullness (less common in patients
with NP)
● Decreased or loss of smell (more common in patients
with NP)
● Objective evidence of inflammation
● Purulent mucous or edema in the middle meatus or
ethmoid region
● NP
● CT without contrast demonstrating inflammation in the
paranasal sinuses (more commonly recommended for
endonasal tumors)
During the workup for CRS or recurrent acute
rhinosinusitis, what comorbidities should be
investigated that might modify management?
● Allergic rhinitis ● Cystic fibrosis ● Immunocompromise ● Ciliary dyskinesia ● Anatomical abnormality
What is the classic triad associated with
Kartagener syndrome?
● Situs inversus
● Bronchiectasis
● CRS
Note: Caused by a dynein arm defect; autosomal recessive
What percentage of patients with CRS will also
have asthma?
50%
If patients with CRS do not improve with standard
therapy, allergy testing may be considered because
60% of these patients have significant allergies.
What are the most common allergens implicated?
Perennial allergens: Dust mites, cockroaches, pet dander,
fungi
What diagnosis is given to patients who have
aspirin sensitivity, NP, and asthma?
Samter triad
What cytokine, or proinflammatory mediator, is thought to be primarily involved in Samter triad
patients?
Leukotrienes
What bacterial antigen is thought to be associated
with nonspecific T-cell activation and cytokine
release via cross linking of T-cell receptors with
major histocompatibility class (MHC) II receptors on
antigen presenting cells, and has been hypothesized
to be involved in the pathogenesis of CRS with NP?
Staphylococcal superantigen
What term defines the organized, three-
dimensional bacterial structures encased in an
extracelluar matrix, which protects it from conven-
tional treatment modalities and may contribute to
some cases of CRS?
Bacterial biofilms
In patients with refractory rhinosinusitis, according
to Chee et al (Laryngoscope 2001), what
underlying immunodeficiencies may be identified?
● Combined variable immunodeficiency (10%)
● Selective IgA deficiency (6%)
● Low titers of IgG (18%), IgA (17%), or IgM (5%)
What is the prevalence of rhinosinusitis in the HIV
population?
20 to 70%. Patients with HIV are at increased risk because of
lymphocyte dysfunction and increased mucociliary trans-
port time.
What laboratory tests should be considered for a
patient with refractory CRS or recurrent acute
rhinosinusitis to evaluate for an underlying
immunodeficiency?
● Quantitative immunoglobulin assays (IgG, IgA, IgM)
● Antibody response to tetanus toxoid and pneumococcal
vaccines (before and after vaccination)
● T-cell number and function
What is the genetic inheritance and cause of CRS
in cystic fibrosis?
Autosomal recessive disorder causes abnormally tenacious
exocrine gland secretions involving multiple organ systems.
Patients with cystic fibrosis universally develop chronic
sinusitis as a result of tenacious sinonasal secretions.
Describe the management of CRS in patients with
cystic fibrosis.
Conservative management is with mucolytics, topical anti-
biotic irrigations, and saline irrigations. The patient may need aggressive endoscopic surgical management followed by nasal saline irrigations and antipseudomonal antibiotic irrigations (tobramycin, especially if he or she is undergoing
lung transplant.
What findings on CT scan should be specifically
evaluated for when evaluating a patient with CRS or recurrent acute rhinosinusitis?
● Mucosal inflammation
● Osseous destruction, extrasinus extension, or local
invasion suggestive of aggressive disease or a malignant
process
● Anatomical abnormalities: Septal deviation, concha bul-
losa, Haller cell, maxillary sinus hypoplasia, and/or
obstruction of the osteomeatal complex
What staging system grades the amount of
mucosal disease present in the left and right
frontal, anterior/posterior ethmoid, maxillary and
sphenoid sinuses (0 = clear, 1 = partial opacification,
2 = complete opacification) and ostiomeatal complex
(0 = clear, 2 = occluded)?
Lund-Mackay system (Annals of Otology, Rhinology, and
Laryngology, 1995)
Although bacterial infection in CRS is often related
to more common pathogens such as Staphylococcus
aureus, Pseudomonas aeruginosa, Klebsiella pneumo-
niae, and Proteus mirabilis, over time, more rare
anaerobic infections can occur. Name three such
pathogens.
● Fusobacterium spp.
● Peptostreptococcus spp.
● Prevotella spp.
What are the three primary subtypes of CRS?
● CRS with NP
● CRS without NP
● Allergic fungal rhinosinusitis
What is a key difference between the
inflammation seen in CRS with and without NP?
Without NP: Neutrophils
Without NP: Eosinophils; interleukin-5 (IL-5) also increased
What is the treatment recommended for CRS
without NP (European Position Paper on RS and
NP, 2007, supported 2012)?
Mild disease (visual analog scale: 0 to 3)
● Topical corticosteroids
● Nasal saline irrigation
● If no improvement in 3 months, treat as moderate/severe
Moderate/severe disease (visual analog scale: 4–10)
● Topical corticosteroids
● Nasal saline irrigation
● Long-term macrolide treatment (~3 months) (if IgE is not
elevated)
● Culture
● If no improvement: Consider CT and surgical candidacy
● If improvement noted: Continue close follow-up, nasal irrigation, and topical corticosteroids. Consider continuation of long-term macrolide treatment
Note: Evidence for the 3-month duration cutoff is lacking.
Name the four macrolides that can be considered
for long-term antibiotic therapy in CRS without
NP?
● Azithromycin
● Clarithromycin
● Roxithromycin
● Erythromycin
What is the treatment recommended for CRS with
NP (European Position Paper on RS and NP, 2007)?
Mild disease (visual analog scale: 0 to 3)
● Topical corticosteroids for 3 months
● Benefit noted → continue therapy and review every 6
months
● No benefit → 1 month of oral corticosteroid
● Benefit noted → continue or switch back to topical
corticosteroid drops; review after 3 months
● No benefit → CT, consider surgical candidacy
Moderate disease (visual analog scale: 4 to 7)
● Topical corticosteroid drop for 3 months
● Benefit noted → continue and review every 6 months
● No benefit → 1 month of oral corticosteroid
● Benefit → continue or switch back to topical corticoste-
roid drop
● No benefit → CT; consider surgical candidacy Severe disease (visual analog scale: 8 to 10)
● 1-month course of oral corticosteroid + topical cortico-
steroid
● Benefit → continue topical corticosteroid drops only and
review every 3 months
● No benefit → CT; consider surgical candidacy
Note: Antibiotics are not recommended by these guidelines.
Evidence for the 3-month duration cutoff, topical cortico-
steroid drop vs. spray, and 1 month of steroid therapy is controversial.
What is the only Food and Drug Administration
(FDA)-approved topical corticosteroid spray for NP?
Mometasone furoate
What are indications for endoscopic sinus surgery
in patients with CRS?
● Allergic fungal rhinosinusitis
● Failed medical therapy
● Anatomical abnormalities that hinder sinus drainage or
medication application
● Significant NP
● Complications of rhinosinusitis or previous therapy (e.g.,
mucoceles, synechiae, etc.)
After surgical intervention with polypectomy for
CRS with NP, what medical management is
recommended?
Maintenance therapy with topical corticosteroids and nasal
irrigation
What are the most common sites for extrasinus
complications associated with rhinosinusitis
(generally acute or acute-on-chronic)?
● Orbital (60 to 75%)
● Intracranial (15 to 20%)
● Bony (5 to 10%)
Name the valveless veins that allow retrograde
spread of thrombophlebitis from mucosal veins to
emissary veins, which pass through the diploe
between the anterior and posterior tables of cranial
cancellous bone to subdural veins and ultimately to
cerebral veins.
Veins of Breschet (also known as diploic veins)
What term refers to the paralysis or paresis of
one or more of the extraocular muscles?
Ophthalmoplegia
Describe the classification system used for orbital
complications associated with rhinosinusitis.
Chandler classification groups ● Preseptal cellulitis ● Orbital cellulitis ● Subperiosteal abscess ● Orbital abscess ● Cavernous sinus thrombosis
You are evaluating a patient with acute
rhinosinusitis who has unilateral eyelid edema,
periorbital erythema, and tenderness with no
evidence of proptosis, visual change, or restriction
of ocular muscle movement. Imaging suggests
rhinosinusitis and inflammation/infection of the
periorbital soft tissues anterior to the orbital septum.
What is the most likely diagnosis?
Preseptal cellulitis (Chandler group 1)
What is the treatment for preseptal cellulitis?
Medical therapy: IV antibiotics (may consider oral), warm compresses, elevation of the head of the bed, decongest-
ants, mucolytics, and sinus irrigation. Close follow-up
You are evaluating a patient with acute
rhinosinusitis who has unilateral eyelid edema and
erythema, proptosis, chemosis, normal vision, de-
creased extraoccular motility, and pain. CT scan
shows an area of low attenuation adjacent to the
lamina papyracea but no discrete abscess. What is
the likely diagnosis?
Orbital cellulitis (Chandler group 2)
Although most patients with orbital cellulitis
should be treated with medical management
(similar to preseptal cellulitis), what are two indica-
tions that a patient will need surgical drainage?
● Visual acuity ≤ 20/60
● Worsening or lack of improvement after 48 hours of
medical therapy
You are evaluating a patient with acute
rhinosinusitis who has unilateral proptosis,
chemosis, and ophthalmoplegia with decreased
visual acuity and significant orbital pain. CT scan
demonstrated a rim-enhancing hypodensity with
mass effect adjacent to the lamina propria. What
is the likely diagnosis?
Subperiosteal abscess (Chandler group 3)
Although medical cure is possible in patients with subperiosteal abscesses with the use of IV
antibiotics, warm compresses, and nasal decongestants/irrigation/mucolytics, surgical intervention is recommended for worsening visual
acuity, increased restriction of range of motion, or lack of improvement after 48 hours. What
approaches can be used?
● Endonasal endoscopic drainage: medial abscess
● External ethmoidectomy via a Lynch incision
● Transcaruncular transconjunctival approach
You are evaluating a patient with acute rhinosinusitis who has unilateral severe ophthalmo-
plegia, chemosis, proptosis, severe vision loss, and
pain. CT scan demonstrates fluid collection within
the orbital tissue. What is the likely diagnosis?
Orbital abscess (Chandler group 4)
What syndrome, which can result from an orbital abscess, is associated with ptosis, proptosis, oph-
thalmoplegia, a fixed and dilated pupil, and V1 anesthesia?
Superior orbital fissure syndrome
What syndrome, which can result from an orbital abscess, is associated with ptosis, proptosis, oph-
thalmoplegia, a fixed and dilated pupil, V1
anesthesia, and vision loss?
Orbital apex syndrome
True or False. Orbital abscesses associated with
rhinosinusitis can be managed with outpatient
antibiotics, decongestants, and an ophthalmology
consultation with close follow-up.
False. Inpatient admission, IV antibiotics, decongestants,
and a low threshold for surgical drainage
You are evaluating a patient with acute
rhinosinusitis who has bilateral orbital pain,
proptosis, chemosis, ophthalmoplegia, V2 sensory
loss, sepsis, and meningismus. CT is suggestive
of a process within the cavernous sinus, and MRI
demonstrates heterogeneity and increased size of
the sinus. What is the likely diagnosis?
Cavernous sinus thrombosis (Chandler group 5)
What imaging modality is best to diagnose a
cerebral venous sinus thrombosis?
MRI (T1, T2, T2 echo, and MR venography)
The primary treatment for cavernous sinus throm-
bosis associated with rhinosinusitis includes IV
antibiotics, management of increased intracranial
pressure, management of predisposing factors,
surgical drainage of associated abscesses, and/or
sinuses. When should anticoagulation be used?
This topic is controversial! Although anticoagulation may
decrease the propagation of thrombosis, it also increases
the risk of intracranial bleeding.
Describe the symptoms of cavernous sinus
thrombosis.
Orbital pain; conjunctival and lid edema; vision loss;
proptosis; exophthalmos; photophobia; cranial nerves II, III,
IV, V1, and VI involvement.
Name the five intracranial complications associated
with rhinosinusitis.
● Meningitis ● Epidural abscess ● Subdural abscess ● Intracerebral abscess ● Cavernous sinus or venous sinus thrombosis
What symptoms are frequently seen in patients
with intracranial complications associated with rhinosinusitis?
Fever, headache, nausea or vomiting, altered mental status,
focal neurologic signs, seizures, visual changes, and meningismus
What management strategies are frequently used in patients with intracranial complications of rhinosinusitis?
IV antibiotics, often 4 to 8 weeks. Management of elevated
intracranial pressure. (Note: Lumbar puncture is often
contraindicated). Possible surgical drainage: endonasal and
intracranial (bur hole vs. craniotomy, needle aspiration vs.
resection)
Why are steroids considered controversial in the
management of intracerebral abscesses?
Steroids can result in decreased encapsulation of the
abscess, increased necrosis, increased risk of rupture into
the ventricular system, decreased antibiotic penetration
into the abscess, and possible rebound edema after
discontinuation.
Thrombophlebitic spread of infectious material
from acute bacterial rhinosinusitis into the
adjacent bone with resulting osteomyelitis can
occur via which vascular structures?
Diplopic veins (veins of Breschet)
A patient with a history of CRS has a recent
exacerbation and new-onset headache, fever,
nasal congestion, and rhinorrhea. On examination,
you note an area of swelling, erythema, and
fluctuance over the frontal bone. On CT, you
note a frontocutaneous fistula through the anterior
table. What is the diagnosis?
Pott puffy tumor
What are the cornerstones for management of
Pott puffy tumor?
● Surgical drainage and removal of infected bone
● IV antibiotic therapy continued for 6 weeks
What percentage of Pott puffy tumors can be
associated with additional periorbital, pericranial,
or intracranial abscesses?
60%
Describe the origin of a sinonasal mucocele.
Sinus ostial obstruction leading to mucus accumulation.
Origins include mucus retention cyst, trauma, inflammation
(chronic sinusitis, allergy), iatrogenic surgical injury, polyposis, and osteoma.
Which paranasal sinuses are most frequently
involved by mucoceles?
The frontal sinus is most commonly involved, followed by
ethmoid sinus involvement. Maxillary and sphenoid sinuses
are less frequently involved.
Why might a patient have an enlarged sinus or
dehiscent area of bone associated with a known
mucocele?
Mucocele growth is expansile and can result in bony
remodeling.
