Chapter 25 - Acute Rhinosinusitis, Complications

Question 1

Chandler classification

Answer 1

I- preseptal
II- orital
III- subperiosteal abscess
IV- orbital ascess
V- CST

Question 2

How long can “acute” rhinosinusitis last?

Answer 2

4 wk to be called acute

Question 3

Recurrent acute rhinosinusitis

Answer 3

4+ episodes of ABRS per year, no persistent sx between episodes

Question 4

Percentage of adults with rhinosinusitis

Percentage who get infectious complications

Answer 4

13. 4%

0. 01% kids, less adults, but higher if immunocomp

Question 5

Diagnosing bacterial rhinosinusitis

Answer 5

Major: purulent rhinorrhea, nasal obstruction, facial pressure/pain, fever, hyposomia
Minor: cough, malaise, maxillary tooth pain, ear full/pressure
Time: Persistent at least 10d, or worsening after 5d of initially improving sx, severe sx 3-4 days including high fever (102.2/39), and purulent discharge or facial pain

Question 6

Less common ABRS bacteria

Answer 6

S pyogenes, S aureus, GNR, anaerobes

Question 7

Percentage of H Flu and M Catarralis producing B lactams

Answer 7

H Flu 30%
M Cat 90%
Augmentin works against bugs with B lactamase
S Pneumo also has 30% resistance to penicillin/macrolide

Question 8

Goals of antibiotics for ABRS

Answer 8

Decrease severity and duration, prevent infxn complication, or progression to chronic, restore QOL

Question 9

How long it takes to get better on your own with bacterial sinusitis w/o ABx

Answer 9

60-70% will resolve spontaneously within 7-12 days

Question 10

ABx for ABRS (1st and 2nd line)

Answer 10

1st: Amoxil, Augmentin
2nd: Macrolide, Bactrim, Doxy, 2/3 Ceph (cefpodoxime, cefixime, cefdinir), clinda, levo/moxi

Recommend giving clinda in addition to oral cephs due to variable resistance

Question 11

When to change or stop ABx

Answer 11

Duration is 5-10d adults, 10-14d children, for uncomplicated

If worsen after 2-3 days or fail to improve after 3-7 days, then consider resistance or non-infectious etiology

Question 12

Adjuvant treatments for ARS

Answer 12

Nasal saline, steroid
Decongest, histamine, mucolytics
Analgesia (start with tylenol)

Question 13

Where to Cx

Answer 13

Consider middle meatus as a surrogate Cx of sinus

Need 10^4 colony-forming units

Question 14

When to get imaging for rhinosinusitis

Answer 14

Recurrent acute (4+ per year), severe cases, suspect suppurative complications

CT, use contrast if suspect orbital or cranial abscess
MRI with gad if suspect CNS involve

Question 15

RF for ABx resistance

Answer 15

<2 >65, daycare, abx within last month, recent hospital, immunosuppress, comorbid
Strongly consider Cx in these pts

Question 16

Suppurative complications of ABRS

Answer 16

Orbital involve (2/2 ethmoid sinusitis)
Meningitis (2/2 sphenoid sinusitis usually)
Epidural/Subdural abscess (frontal sinusitis)
Brain abscess, venous thromb, mucocele/mucopyocele, frontal bone osteomyelitis (Pott Puffy Tumor)

Question 17

How to diff orbital cellulitis from preseptal

Answer 17

Orbital: impair EOM, proptosis, chemosis

Question 18

What is a subperiosteal ascess

Answer 18

Pus between lamina and medial periorbita

Globe may be inferolaterally displaced

Question 19

When you think an orbital abscess has occurred

Answer 19

severe visual impairment

complete ophthalmoplegia

Question 20

How to treat subperiosteal abscess in children

Answer 20

If <0.5-1ml in volume, medial, normal visual acuity, no systemic involvement, may manage medically
Surgery if no improve 1-2 days
Surgery would be ethmoidectomy, drain abscess

Question 21

Three ways fungi can cause acute rhinosinusitis

Answer 21

Allergic fungal rhinosinusitis: Atopic pt, fungi cause IgE HSR; Nasal polyposis, allergies, allergic mucin with eosinophils, Charcot-leyden crystals, fungal hyphae

Fungus ball/mycetoma: Non-atopic pt, non-invasive, NL immune

IFS: Immunocompromised, invade vessels/ST/bone

Question 22

Treatment of fungal ARS

Answer 22

All require surgery to remove fungal organism, but also use systemic antifungals for IFS