HEENT 06: Sinusitis Flashcards
What is acute sinusitis?
symptoms for < 4 weeks, ≤ 3 episodes per year
What is chronic sinusitis?
symptoms for ≥ 12 weeks
What is recurrent sinusitis?
≥ 4 symptomatic episodes per year, complete resolution of symptoms between episodes
What are the causative organisms of sinusitis?
viral – 90%
bacterial
- Streptococcus pneumoniae
- Hemophilus influenzae
- Moraxella catarrhalis – 25% in children, infrequent in adults
- less common pathogens: Staphylococcus aureus, Group A Streptococci, anaerobes (acute)
What are the risk factors for sinusitis?
- recent viral URTI
- asthma
- allergic rhinitis, rhinitis medicamentosa
- smoking or exposure to second-hand smoke
- anatomy – deviated septum, turbinate deformity
What are the signs and symptoms of sinusitis?
- facial pain, pressure or fullness
- referred pain to ears, teeth
- headache
- purulent nasal discharge
- fever
- altered smell, taste
- halitosis
- cough
- malaise
PODS: facial Pain, nasal Obstruction, purulent nasal Discharge, Smell disorder
What are the most common symptoms of sinusitis in children?
- cough
- rhinorrhea
How is viral vs. bacterial sinusitis differentiated?
based on symptom timeline
- individual signs/symptoms cannot be used to distinguish between bacterial and viral infection
What is the clinical presentation of viral sinusitis?
- symptoms peak rapidly, start to decline by 3rd day, end in 1 week
- symptoms may last longer in 25% of cases, but will be improving overall
What is the clinical presentation of bacterial sinusitis?
- 10 days or longer without improvement
- severe symptoms and high fever (> 39ºC) with purulent discharge or facial pain for 3-4 consecutive days at start of illness
- symptoms start to improve, then worsen by 5-7 days
How long do symptoms last?
- symptoms may last up to 1 month
- most symptoms resolve within 1 week
Are cultures used for sinusitis diagnosis?
no – not helpful in identifying pathogen (colonization)
Is diagnostic imaging used for sinusitis diagnosis?
- sinus x-rays do not differentiate between viral URTI and bacterial sinusitis
- CT scan considered if chronic sinusitis not responding to treatment
- colour of nasal discharge/sputum not used to diagnose sinusitis as bacterial – colour related to presence of neutrophils, NOT bacteria
What are the adjunctive treatments for sinusitis?
- intranasal corticosteroids
- analgesics
- nasal saline irrigation or steam inhalation
- decongestants (oral or nasal spray)
Intranasal Corticosteroids
- reduce inflammation to promote sinus drainage and improve sinus ventilation
- use in sinusitis is controversial
- consider for mild to moderate disease – reassess in 72 hours
When is a referral required?
- signs of periorbital or orbital cellulitis (eye pain, high fever, swelling around eye, decreased vision)
- blindness or impaired visual acuity or double vision
- altered mental status, confusion
- sign of intracranial complications (high fever, severe headache, stiff neck) – ie. brain abscess, meningitis
What is drug-induced rhinitis medicamentosa (rebound congestion)?
- non-allergic rhinitis due to prolonged topical vasoconstrictors presenting with reactive swelling of nasal turbinates, increased watery secretions
- caused primarily by topical decongestants: (phenylephrine/pseudoephedrine, naphazoline, oxymetazoline)
How should rebound congestion be managed?
discontinue oxymetazoline nasal spray gradually
- preferred over abrupt cessation to reduce discomfort
- tapering strategy: reduce usage to once daily for few days, then stop completely
- alternatively: switch to saline nasal spray to help with moisture and mild relief
initiate intranasal corticosteroid
- ie. fluticasone 50 mcg 2 sprays per nostril once daily
- helps reduce inflammation and congestion
- safe for long-term use and beneficial in managing rebound symptoms
supportive therapy:
- saline nasal irrigation (ie. neti pot or saline spray) to clear mucus and improve nasal breathing
- adequate hydration to thin mucus secretions
- avoid other nasal decongestants (ie. pseudoephedrine) – can worsen the rebound effect
What is the first-line treatment for sinusitis?
amoxicillin
- 500-1000 mg PO TID x 5-7 days
What is the first-line treatment if penicillin allergy?
doxycycline
- 200 mg PO once daily, then 100 mg PO twice daily x 5-7 days
What is the first-line treatment if beta-lactam allergy?
cefixime
- 400 mg PO once daily x 5-7 days
What is the treatment if severe symptoms or first-line is ineffective?
amoxicillin/clavulanate
- 875 mg PO twice daily x 5-7 days
What is the treatment if severe symptoms or first-line is ineffective and penicillin allergy?
doxycycline
- 200 mg PO once daily, then 100 mg PO twice daily x 5-7 days
What is the treatment if severe symptoms or first-line is ineffective and beta-lactam allergy?
levofloxacin
- 750 mg PO once daily x 5 days
What is the treatment for children?
- amoxicillin 40 mg/kg/day PO divided TID x 10 days
- amoxicillin 90 mg/kg/day PO divided BID-TID x 10 days
- consider high dose if < 2 years old, and/or < 3 months due to antibiotic exposure, daycare
What is the treatment for immunocompromised patients?
amoxicillin/clavulanate (7:1) 45 mg/kg/day PO divided BID-TID x 10 days
(+ amoxicillin 45 mg/kg/day divided BID-TID)
What antibiotics are not recommended for treatment?
- due to high resistance: macrolides, SMX/TMP
- fluoroquinolones (ciprofloxacin, levofloxacin) due to
What is considered treatment failure?
- worsening symptoms (clinical deterioration) after 72 hours antimicrobial therapy
- no improvement after complete antimicrobial course
- recurrence within 3 months
What is the treatment for adults if first-line options fail?
- amoxicillin/clavulanate 875 mg PO BID x 5-10 days (+/- amoxicillin 1g PO BID)
- levofloxacin 750 mg PO daily x 5-10 days
What is the treatment for children if first-line options fail?
amoxicillin/clavulanate (7:1) 45 mg/kg/day PO divided BID-TID x 10 days
(+/- amoxicillin 45 mg/kg/day divided BID-TID)
Why is amoxicillin first-line?
- excellent activity vs. S. pneumoniae – local antibiograms show 100% susceptibility to amoxicillin
- some activity vs. H. influenzae in adults locally
- amoxicillin/clavulanate is broad spectrum – may increase risk of antibiotic resistance
When is amoxicillin/clavulanate used for treatment?
- children who are severely ill or immunocompromised – higher rates of beta lactamase-producing H. influenzae strains in children than adults
- situations in which bacterial resistance is likely
- presence of moderate to severe infection
- presence of comorbidity
After pneumococcal vaccination, what is the more common causative pathogens?
shift towards more H. influenzae and M. catarrhalis infections
What is the treatment if failed standard dose amoxicillin therapy?
- high dose amoxicillin to overcome penicillin-intermediate/resistance S. pneumoniae strains + regular dose of amoxicillin-clavulanate for coverage of ampicillin resistant (beta lactamase-producing) H. influenzae and M. catarrhalis without giving excessive clavulanate
- > 10 mg/kg/day clavulanate may lead to diarrhea
- amoxicillin retains best coverage of S. pneumoniae (even majority of penicillin-resistant strains)
What is the treatment if failed high dose amoxicillin therapy?
- failure due to beta lactamase-producing organism
- amoxicillin/clavulanate used alone to cover beta lactamase-producing organisms
- amoxicillin/clavulanate coverage for ampicillin resistant H. influenzae and M. catarrhalis
What is chronic sinusitis caused by?
usually anaerobes
What is the treatment for chronic sinusitis?
repeated courses of antibiotics not recommended – refer to ENT if not responding
