Acute Bacterial Rhinosinusitis Flashcards
Define Rhinosinusitis
Inflammation of the sinonasal mucosa
Classification by timeframe of rhinosinusitis?
- Acute > 7 days
- Chronic > 8-12 weeks
What are the four major and seven minor symptoms of acute bacterial sinusitis?
Canadian Guidelines 2011:
1. Facial pain/pressure/fullness
2. Nasal obstruction
3. Nasal purulence/discoloured postnasal discharge
4. Hyposmia/anosmia
PODS
MINOR SYMPTOMS:
1. Fatigue
2. Ear pain pressure
3. Cough
4. Headache
5. Halitosis
6. Dental pain
Discuss the diagnostic criteria (canadian guidelines) of Acute Bacterial Rhinosinusitis. How does this differ from Post-viral acute rhinosinusitis?
DIAGNOSTIC CRITERIA
- ≥ 7 days of symptoms
- 2+ of PODS criteria: Pressure, Obstruction, Discharge (purulent rhinorrhea), Smell Changes
- At least one of Obstruction or discharge
- Consider ABRS when viral URTI persists >10 days or worsens after 5-7 days, “double worsening
Post-viral ARS: Alternative term coined by EPOS (for less than 10 days)
- Bacterial ARS should not be diagnosed before 10 days duration of symptoms unless there is clear worsening of symptoms after 5 days
Kevan Page 30
List the bacterial etiologies of acute rhinosinusitis, including the top 3 most common
CAUSES:
- 95% of Acute Rhinosinusitis = Viral
3 most common causes of ABRS:
1. Strep pneumoniae
2. Haemophilus Influenzae
3. Moraxella Catarrhalis
Other:
1. Streptococcus pyogenes
2. Peptostreptococcus
3. Fusobacterium
4. Bacteriodes - pseudomonas, e. coli, klebsiella, proteus
What is the treatment of acute bacterial rhinosinusitis per Canadian Guidelines?
TREATMENT:
1. INCS is first line
2. Adjunctive therapies for symptom relief: Analgesics (tylenol/nsaids), oral decongestants, topical decongestants (max 72 hours), saline irrigation
3. Antibiotics can be considered if severe symptoms or if no improvement after 72 hours
- First line antibotics: Amoxicillin, or TMP/SMX or Macrolide if beta lactam allergy
- Second line antibiotics: Clavulin, or Fluoroquinoline
MILD TO MODERATE (Steady symptoms but easily tolerated):
1. Trial of intranasal corticosteroids x 14 days, but reassess in 72 hours
2. In 72 hours, if no clinical response –> antibiotics
SEVERE (Symptoms hard to tolerate and interfere with activity or sleep)
1. INCS + Antibiotics (5-10 days)
What are the 1st line and 2nd line antibiotics for ABRS?
Treat for 10 - 21 days
FIRST LINE:
1. Amoxicillin
2. Beta-lactam allergy: Septra or macrolide (e.g. Clarithromycin)
SECOND LINE:
1. Amoxicillin/clavulanic acid
2. Fluoroquinolones - enhanced G+ (e.g. Moxifloxacin, Levofloxacin, Ciprofloxacin)
3. Cefuroxime
4. Clindamycin
5. Macrolides - Clarithromycin, Azithromycin
NOSOCOMIAL INFECTIONS (pseudomonas):
1. Ampicillin
2. Ceftazidime
3. Piptazo
4. Cipro
5. Imipenem
What are 7 indications for second line therapy in ABRS?
- No clinical response to first line therapy within 72-96 hours
- Patients who received antibiotics in previous 3 months
- Frontal or sphenoid sinusitis
- Allergy to beta lactams
- Chronic underlying conditions
- Immunosuppression
- Protracted symptoms
What is the likelihood of response to antibiotics?
- At least ≥ 3 of:
1. Discolored discharge
2. Severe local pain
3. Fever
4. Elevated ESR/CRP
5. Double sickening
A number of studies show that complications of ABRS are not prevented by routine prescribing of antibiotics
What is the definition of recurrent acute rhinosinusitis?
Canadian + EPOS guidelines:
- Meets the diagnostic criteria, with >4 episodes per year, each lasting ≤ 4 weeks each (OR 3 episodes in 6 months)
- Asymptomatic period between episodes
In office assessment during at least one episode to confirm diagnosis
What is the management of recurrent acute bacterial sinusitis? 3
- Ensure at least one course of intranasal or oral steroids
- Obtain a CT Sinus only if worried about complications
- Offer surgery to patients in whom recurrent ABRS causes significant functional impairment
- Extent of surgery is controverial, but most would do:
- Bilateral anterior ethmoidectomy
- Bilateral maxillary antrostomy
- ± Surgical treatment of patient specific abnormalities on the CT (e.g. Concha bullosa)
Discuss the EPOS Classification for ARS and ABRS
Acute Rhinosinusitis in Adults:
1. 2+ of PODS (Pain, obstruction, discharge, smell changes)
2. < 12 weeks
3. Subdivided into the following:
A. Acute Viral Rhinosinusitis
- aka. common cold
- Symptoms < 10 days
B. Acute Post-Viral Rhinosinusitis
- When symptoms persist > 10 days (but < 12 weeks); OR
- When symptoms worsen after 5 days
C. Acute Bacterial Rhinosinusitis
- Must have at least 3/5 of (FEDDS):
- F: Fever > 38 degrees
- E: Raised ESR/CRP
- D: Discoloured mucous
- D: Double sickening (Where symptoms worsen after initially improving)
- Severe pain
Only a subset of patients with ARS will have post-viral RS, and of those, only a subset will have ABRS, and of those only a subset need antibiotics
What are the frontal veins of Breschet in the frontal bone and what is their significance?
- Perforating VALVELESS veins connecting the intracranial and extracranial venous draining systems
- A potential pathway of hematologic spread of infection
- If not cleared in frontal sinus obliteration, can harbor mucosa and cause mucopyocele formation
What are 4 different ways that sinusitis can spread?
- Hematogenous: Retrograde thrombophlebitis through valveless veins (e.g. veins of Breschet)
- Direct Extension: Preformed pathways (e.g. natural dehiscence of lamina)
- Direct Extension: Trauma/surgical pathways (e.g. traumatic dehiscence of lamina papyracea)
- Direct Extension: Osteomyelitis (e.g. Pott’s puffy tumor
List 11 complications of acute bacterial rhinosinusitis.
EXTRACRANIAL:
1. Pre-septal cellulitis
2. Orbital cellulitis
3. Subperiosteal abscess
4. Orbital abscess
5. Cavernous sinus thrombosis
6. Pott’s puffy tumor
INTRACRANIAL:
1. Meningitis
2. Epidural abscess
3. Subdural abscess
4. Intracranial abscess
5. Superior sagittal sinus thrombosis
