Module 8.11 - Sinusitis

Question 1

What is sinusitis?

Answer 1

An inflammation/infection of the paranasal sinus mucous membrane; may be acute lasting < 4 weeks) or chronic (occurring 3 or more times in a year)

Question 2

What causes sinusitis?

Answer 2

A. Caused by virus 20% of the time.

B. Common organisms:

1. Haemophilus influenza
2. Streptococcus pneumoniae
3. Moraxella catarrhalis

C. Recurrent disease may be to irritants (smoking), allergens, bacteria, fungi

D. Anatomic blockage of sinus openings

E. Nasal polyps, masses, or neoplasms

F. Prolonged nasal intubation or prolonged use of nasogastric tubes.

Question 3

What are the subjective/physical exam findings associated with sinusitis?

Answer 3

A. Recent upper airway infection

B. Pain/pressure over face, nose, cheeks, and teeth

C. Purulent/blood tinged nasal drainage

D. Headache,increased pain insupineor bending position and sense of fullness inhead.

E. Nasal congestion

F. Generalized malaise

G. Orbital pain or visual disturbance

• NOTE * Immediately refer to ENT for swelling of orbital areas or forehead, severe pain or visual disturbance.

H. NOTE* Fever may not be present in the elderly patient.

I. Localized tenderness over the sinuses.

J. Facial edema

K. Swollen, reddened turbinates.

L. Foul smelling nasal or post nasal drainage.

Question 4

What are the 4 primary signs and symptoms of chronic sinusitis?

Answer 4

1. Thick, discolored discharge from the nose or drainage down the back of the throat (postnasal drainage).
2. Nasal obstruction or congestion, causing difficulty breathing through your nose.
3. Pain, tenderness and swelling around your eyes, cheeks, nose or forehead.
4. Reduced sense of smell and taste in adults or cough in children.

NOTE* _At least 2 of the 4_ primary signs and symptoms of chronic sinusitis must be present with confirmation of nasal inflammation for a diagnosis to be made

Question 5

What laboratory/diagnostic tests are used to diagnose sinusitis?

Answer 5

• Usually diagnostic studies are unnecessary.
• Recurrent or persistent sinusitis after a course of antibiotics should be further investigated with sinus x-rays or CT scan of the sinuses.
• CBC may confirm a bacterial cause and a C&S of the nasal discharge may identify causative organisms.

Question 6

How is sinusitis managed?

Answer 6

A. Antibiotics (guided by culture results for chronic sinusitis)

• Amoxicillin/clavulanate (Augmentin) 500mg po tid or 875mg po bid for 7-10 days
  
  • Note* Augmentin may be superior for those patients greater than 65 years of age when used in doses of 2 gms bid for S. Pneumoniae causing the sinusitis.
• Macrolides are NO longer recommended due to the high rate of resistance of S. pneumoniae to these medications.
• Doxycycline 100mg po bid and a respiratory fluoroquinolone (Levofloxacin or moxifloxacin) are reasonable alternatives for patients allergic to PCN
  
  • Levofloxacin 500- 750mg po daily, or Moxifloxacin 400mg po daily

The addition of corticosteroids to the antibiotics has not been convincingly shown to improve therapeutic outcomes.

B. Analgesics (NOTE* Use judiciously among the elderly)

• Acetaminophen (Tylenol) 650mg po q 4 hours (maximum 4 gms daily) with caution given to not use any other acetaminophen containing products.