Acute and Chronic Rhinosinusitis

Question 1

In the past decade, the term rhinosinusitis has

been commonly used to describe what condition?

Answer 1

Inflammation of the nose and paranasal sinuses. This term
is preferred over sinusitis because sinusitis almost always
involves the nasal cavity.

Question 2

According to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007), what
are the criteria for diagnosing rhinosinusitis?

Answer 2

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

Question 3

Describe the five major classifications of

rhinosinusitis based on symptom time course.

Answer 3

● 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

Question 4

What is one of the tools used to assess the

severity of rhinosinusitis symptoms?

Answer 4

● 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

Question 5

Define double worsening/sickening.

Answer 5

Symptoms that worsen following initial improvement

Question 6

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?

Answer 6

Acute viral rhinosinusitis

Question 7

What are the two most common pathogens associated with acute viral rhinosinusitis?

Answer 7

Rhinovirus and Influenza virus

Question 8

What percentage of viral rhinosinusitis is estimated

to progress to bacterial sinusitis?

Answer 8

0.5 to 2%

Question 9

What type of acute rhinosinusitis lasts for > 10 days or manifests with worsening of symptoms after day 5?

Answer 9

Acute bacterial rhinosinusitis (ABRS)

Question 10

In addition to the diagnostic symptoms associated
with rhinosinusitis, what secondary symptoms may
suggest ABRS?

Answer 10

Fever, aural fullness, cough, myalgias, or headache

Question 11

What pathogens are most commonly involved in

ABRS?

Answer 11

● Streptococcus pneumoniae (30%)
● Haemophilus influenzae (20 to 30%)
● Moraxella catarrhalis (10 to 20%)

Question 12

What workup is recommended for acute

rhinosinusitis?

Answer 12

● 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

Question 13

When should you consider a sinus puncture using

a large-bore needle through the canine fossa or inferior meatus for workup of acute rhinosinusitis?

Answer 13

● 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)

Question 14

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?

Answer 14

Symptomatic treatment
● Decongestant
● Saline irrigation
● Analgesics

Question 15

Why do some guidelines on acute rhinosinusitis
recommend against using mucus color to dictate
antibiotic use?

Answer 15

Mucus color is driven by neutrophils, not bacteria.

Question 16

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?

Answer 16

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.

Question 17

For a patient with acute rhinosinusitis with a
temperature > 38oC or in severe pain, what
treatment is recommended?

Answer 17

● 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.

Question 18

When should an antihistamine be used in the treatment of patients with acute rhinosinusitis?

Answer 18

Use antihistamines only in patients with a history of allergic rhinitis or allergic disease.

Question 19

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?

Answer 19

5 days

Question 20

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?

Answer 20

● 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

Question 21

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?

Answer 21

● 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%)

Question 22

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?

Answer 22

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.

Question 23

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?

Answer 23

● 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

Question 24

In penicillin allergic patients, what antibiotics are recommended by the IDSA for adults?

Answer 24

● Doxycycline
● Levofloxacin
● Moxifloxacin
● Cefixime/cefpodoxime and Clindamycin
Not macrolides or trimethoprim-sulfamethoxazole because
of concern for resistance

Question 25

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?

Answer 25

● 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).

Question 26

When should surgical intervention be considered | for patients with acute rhinosinusitis?

Answer 26

Only if complications are present that would benefit from surgical intervention or for recurrent acute rhinosinusitis thought to be caused by an anatomical abnormality

Question 27

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)?

Answer 27

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)

Question 28

During the workup for CRS or recurrent acute rhinosinusitis, what comorbidities should be investigated that might modify management?

Answer 28

``` ● Allergic rhinitis ● Cystic fibrosis ● Immunocompromise ● Ciliary dyskinesia ● Anatomical abnormality ```

Question 29

What is the classic triad associated with | Kartagener syndrome?

Answer 29

● Situs inversus ● Bronchiectasis ● CRS Note: Caused by a dynein arm defect; autosomal recessive

Question 30

What percentage of patients with CRS will also | have asthma?

Answer 30

50%

Question 31

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?

Answer 31

Perennial allergens: Dust mites, cockroaches, pet dander, | fungi

Question 32

What diagnosis is given to patients who have | aspirin sensitivity, NP, and asthma?

Answer 32

Samter triad

Question 33

What cytokine, or proinflammatory mediator, is thought to be primarily involved in Samter triad patients?

Answer 33

Leukotrienes

Question 34

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?

Answer 34

Staphylococcal superantigen

Question 35

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?

Answer 35

Bacterial biofilms

Question 36

In patients with refractory rhinosinusitis, according to Chee et al (Laryngoscope 2001), what underlying immunodeficiencies may be identified?

Answer 36

● Combined variable immunodeficiency (10%) ● Selective IgA deficiency (6%) ● Low titers of IgG (18%), IgA (17%), or IgM (5%)

Question 37

What is the prevalence of rhinosinusitis in the HIV | population?

Answer 37

20 to 70%. Patients with HIV are at increased risk because of lymphocyte dysfunction and increased mucociliary trans- port time.

Question 38

What laboratory tests should be considered for a patient with refractory CRS or recurrent acute rhinosinusitis to evaluate for an underlying immunodeficiency?

Answer 38

● Quantitative immunoglobulin assays (IgG, IgA, IgM) ● Antibody response to tetanus toxoid and pneumococcal vaccines (before and after vaccination) ● T-cell number and function

Question 39

What is the genetic inheritance and cause of CRS | in cystic fibrosis?

Answer 39

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.

Question 40

Describe the management of CRS in patients with | cystic fibrosis.

Answer 40

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.

Question 41

What findings on CT scan should be specifically | evaluated for when evaluating a patient with CRS or recurrent acute rhinosinusitis?

Answer 41

● 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

Question 42

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)?

Answer 42

Lund-Mackay system (Annals of Otology, Rhinology, and | Laryngology, 1995)

Question 43

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.

Answer 43

● Fusobacterium spp. ● Peptostreptococcus spp. ● Prevotella spp.

Question 44

What are the three primary subtypes of CRS?

Answer 44

● CRS with NP ● CRS without NP ● Allergic fungal rhinosinusitis

Question 45

What is a key difference between the | inflammation seen in CRS with and without NP?

Answer 45

Without NP: Neutrophils | Without NP: Eosinophils; interleukin-5 (IL-5) also increased

Question 46

What is the treatment recommended for CRS without NP (European Position Paper on RS and NP, 2007, supported 2012)?

Answer 46

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.

Question 47

Name the four macrolides that can be considered for long-term antibiotic therapy in CRS without NP?

Answer 47

● Azithromycin ● Clarithromycin ● Roxithromycin ● Erythromycin

Question 48

What is the treatment recommended for CRS with | NP (European Position Paper on RS and NP, 2007)?

Answer 48

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.

Question 49

What is the only Food and Drug Administration | (FDA)-approved topical corticosteroid spray for NP?

Answer 49

Mometasone furoate

Question 50

What are indications for endoscopic sinus surgery | in patients with CRS?

Answer 50

● 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.)

Question 51

After surgical intervention with polypectomy for CRS with NP, what medical management is recommended?

Answer 51

Maintenance therapy with topical corticosteroids and nasal | irrigation

Question 52

What are the most common sites for extrasinus complications associated with rhinosinusitis (generally acute or acute-on-chronic)?

Answer 52

● Orbital (60 to 75%) ● Intracranial (15 to 20%) ● Bony (5 to 10%)

Question 53

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.

Answer 53

Veins of Breschet (also known as diploic veins)

Question 54

What term refers to the paralysis or paresis of | one or more of the extraocular muscles?

Answer 54

Ophthalmoplegia

Question 55

Describe the classification system used for orbital | complications associated with rhinosinusitis.

Answer 55

``` Chandler classification groups ● Preseptal cellulitis ● Orbital cellulitis ● Subperiosteal abscess ● Orbital abscess ● Cavernous sinus thrombosis ```

Question 56

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?

Answer 56

Preseptal cellulitis (Chandler group 1)

Question 57

What is the treatment for preseptal cellulitis?

Answer 57

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

Question 58

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?

Answer 58

Orbital cellulitis (Chandler group 2)

Question 59

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?

Answer 59

● Visual acuity ≤ 20/60 ● Worsening or lack of improvement after 48 hours of medical therapy

Question 60

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?

Answer 60

Subperiosteal abscess (Chandler group 3)

Question 61

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?

Answer 61

● Endonasal endoscopic drainage: medial abscess ● External ethmoidectomy via a Lynch incision ● Transcaruncular transconjunctival approach

Question 62

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?

Answer 62

Orbital abscess (Chandler group 4)

Question 63

What syndrome, which can result from an orbital abscess, is associated with ptosis, proptosis, oph- thalmoplegia, a fixed and dilated pupil, and V1 anesthesia?

Answer 63

Superior orbital fissure syndrome

Question 64

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?

Answer 64

Orbital apex syndrome

Question 65

True or False. Orbital abscesses associated with rhinosinusitis can be managed with outpatient antibiotics, decongestants, and an ophthalmology consultation with close follow-up.

Answer 65

False. Inpatient admission, IV antibiotics, decongestants, | and a low threshold for surgical drainage

Question 66

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?

Answer 66

Cavernous sinus thrombosis (Chandler group 5)

Question 67

What imaging modality is best to diagnose a | cerebral venous sinus thrombosis?

Answer 67

MRI (T1, T2, T2 echo, and MR venography)

Question 68

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?

Answer 68

This topic is controversial! Although anticoagulation may decrease the propagation of thrombosis, it also increases the risk of intracranial bleeding.

Question 69

Describe the symptoms of cavernous sinus | thrombosis.

Answer 69

Orbital pain; conjunctival and lid edema; vision loss; proptosis; exophthalmos; photophobia; cranial nerves II, III, IV, V1, and VI involvement.

Question 70

Name the five intracranial complications associated | with rhinosinusitis.

Answer 70

``` ● Meningitis ● Epidural abscess ● Subdural abscess ● Intracerebral abscess ● Cavernous sinus or venous sinus thrombosis ```

Question 71

What symptoms are frequently seen in patients | with intracranial complications associated with rhinosinusitis?

Answer 71

Fever, headache, nausea or vomiting, altered mental status, | focal neurologic signs, seizures, visual changes, and meningismus

Question 72

What management strategies are frequently used in patients with intracranial complications of rhinosinusitis?

Answer 72

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)

Question 73

Why are steroids considered controversial in the | management of intracerebral abscesses?

Answer 73

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.

Question 74

Thrombophlebitic spread of infectious material from acute bacterial rhinosinusitis into the adjacent bone with resulting osteomyelitis can occur via which vascular structures?

Answer 74

Diplopic veins (veins of Breschet)

Question 75

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?

Answer 75

Pott puffy tumor

Question 76

What are the cornerstones for management of | Pott puffy tumor?

Answer 76

● Surgical drainage and removal of infected bone | ● IV antibiotic therapy continued for 6 weeks

Question 77

What percentage of Pott puffy tumors can be associated with additional periorbital, pericranial, or intracranial abscesses?

Answer 77

60%

Question 78

Describe the origin of a sinonasal mucocele.

Answer 78

Sinus ostial obstruction leading to mucus accumulation. Origins include mucus retention cyst, trauma, inflammation (chronic sinusitis, allergy), iatrogenic surgical injury, polyposis, and osteoma.

Question 79

Which paranasal sinuses are most frequently | involved by mucoceles?

Answer 79

The frontal sinus is most commonly involved, followed by ethmoid sinus involvement. Maxillary and sphenoid sinuses are less frequently involved.

Question 80

Why might a patient have an enlarged sinus or dehiscent area of bone associated with a known mucocele?

Answer 80

Mucocele growth is expansile and can result in bony | remodeling.