ENT- Acute and Chronic Rhinosinusitis Flashcards
Acute Rhinosinusitis- epidemiology
1 in 7-8 persons annually
women>men
45-74 y/o
Acute Rhinosinusitis- Etiology
Viral: Rhinovirus, influenza virus, parainfluenza
Bacterial: 0.5-2% of cases
What are risk factors for Acute Rhinosinusitis?
- Older age
- Smoking
- Air travel
- Changes in atmospheric pressure (deep sea diving)
- Swimming
- Asthma
- Allergies
- Dental disease
- Immunodeficiency
Acute Rhinosinusitis- Pathophysiology
Normal sterile environment–> mucosal edema and sinus inflammation–> decreased drainage of thick secretions–> Obstruction of sinus ostia –> entrapment of bacteria leads to infection
Symptoms of acute rhinosinusitis?
- Nasal congestion/ obstruction*
- Purulent nasal discharge*
- Facial pain or pressure*
- Maxillary tooth discomfort
- Fever
- Fatigue
- Cough
- hyposmia or anosmia
- Ear pressure or fullness
- Headache
- Halitosis
*= biggest indicators that sxs are due to a sinus infection and not the common cold
Signs/ physical exam
- Erythema and edema of cheek bone or periorbital
- TTP of sinuses
- cheek tenderness
- Percussion of upper teeth tenderness
- purulent drainage in nose or pharynx
- sinus pain with percussion
- opacity of sinuses with transillumination
- diffuse nasal mucosal edema, turbinate hypertrophy
Acute Rhinosinusitis- Red Flags
- High fever (>102) with severe headache
- Abnormal vision (diplopia, blindness)
- Abnormal EOMs
- Proptosis
- Opthalmoplegia
- Papilledema
- Change in mental status
- periorbital edema or erythema
- Cranial nerve palsies
- Altered mental status
- neck stiffness or other meningeal signs
How do you diagnose Acute Rhinosinusitis?
Diagnosis is made based on clinical impression (based on H&P).
Imaging should only be ordered if any red flags are present
When are radiologic studies indicated in the diagnosis of acute rhinosinusitis?
- Indicated if suspect complicated ABRS:
- CT w/ contrast
- Diminished visual acuity, diplopia, periorbital edema, severe headache, AMS - Recurrent or treatment resistent sinusitis
- noncontrast CT
What are features of acute rhinosinusitis due to a bacterial cause?
- Persistent symptoms or signs lasting 10 or more days with no clinical improvement
- Onset with severe symptoms (fever > 102; purulent nasal discharge, facial pain) lasting at least 3 consecutive days at the beginning of illness
- Onset with worsening symptoms following a viral URI that lasted 5-6 days and was initially improving (“double-worsening”)
What is the treatment for Acute Rhinosinusitis for days 1-9?
Supportive care:
- Analgesics/antipyretics
- Saline irrigation**- very important!
- Intranasal glucocorticoids
- oral decongestants
- topical decongestants
- Mucolytics
What is first line treatment for antimicrobial management of acute rhinosinusitis?
Amoxicillin-clavulanate (Augmentin) 500/125mg TID or 875/125mg BID
Can give higher doses in special situations (>65y/o, recent hospitalization, abx tx in past month, immunocomprimised, S. pneumo pencillin resistance >10%)–> give 2g PO BID
Duration of treatment: IDSA guidelines recommend 5-7 days
What is NOT recommended treatment for acute rhinosinusitis?
Macrolides (Z-pack)
Trimethoprim-sulfamethoxazole (Bactrim)
Acute rhinosinusitis- Indications for referral
- Need for urgent endoscopy or surgical biopsy:
- Severe infection
- Fungal sinusitis or granulomatous disease is suspected
- Nosocomial infection
- Anatomic defects causing obstruction
- Immunocompromised
- Failure to respond to 1st and 2nd line antimicrobial tx
- Multiple recurrent episodes
- Chronic rhinosinusitis w/ recurrent exacerbations of ABRS
- Allergic rhinitis and candidate for immunotherapy