Rhinosinusitis Flashcards
Definition Sinusitis, Rhinitis, Rhinosinusitis
Sinusitis: Inflammation of one or more paranasal sinuses (allergic, viral, bacterial, rarely fungal)
Acute < 4 weeks
Recurrent: > 4 episodes per year lasting more than 10 days each AND no symptoms in between
Chronic: > 12 weeks +/- Symptoms
Rhinitis: Inflammation of the nasal mucosa (viral, allergic)
Rhinosinusitis: inflammation of the nasal mucosa + lining of the sinus (allergic, viral) 200 times more common than sinusitis
What are the risk factors of rhinosinusistis?
- Medical conditions (CF, allergic rhinitis, immunodeficiency, Wegener granulomatosis, Kartagener’s syndrome)
- Irritants (tobacco, air pollution, chlorine)
- Anatomic (deviated septum, adenoidal hypertrophy, immotile cilia, polyps, tumors, foreign body)
- Medications (overuse of topical decongestant, cocaine abuse)
- Trauma (dental procedure, diving)
What is the etiology of Rhinosinusitis?
Acute: S. pneumonia, H. influenza
Chronic: S.aureus, pseudo, Enterobacteriaceae
Children: Moraxella cattarhalis
What are the symptoms of rhinosinusits?
When to think about rhinosinusitis?
Persistent symptoms of URTI, no improvement after 10 days
Purulent discharge nasal
Continued unwell state
Fever, cough, irritability, lethargy, facial pain
In adults:
Persistent symptoms of URTI, no improvements after more than 10 days or worsening in 5 days after initial improvement
Nasal congestion- purulent discharge
Unilateral facial pain-Pressure-Fullness
Fever
Maxillary toothache
Facial swelling
Halitosis, hyposmia, anosmia, ear pain/fullness/pressure, fatigue, cough, facial pain worsen with bending
how to make a diagnosis of acute bacterial sinusitis
More than 2 PODS for more than 7 days or with biphasic fever:
Pain-Pressure
Nasal OBSTRUCTION
Nasals purulence or DISCHARGE
SMELL disorder
Williams criteria:
>or equal to 4
- Maxillary toothache
- purulent nasal discharge
- Poor response to oral decongestants
- Transillumination abnormal
- Coloured nasal discharge
Diagnosis of chronic Rhinosinusitis
CPODS
Congestion-Fullness
Pain (facial pressure-fullness)
Obstruction
Drainage (purulent)
Smell (hyposmia, anosmia)
Dx: >2 CPDOS for 8-12 weeks PLUS inflammation of sinus mucosa
Most confirm w/CT or endoscopy but need clinical as inflammation can occur in up to 48% asymptomatic patients
What can we see on the physical exam of rhinosinusitis?
Face: swelling, erythema, tenderness over paranasal sinus
Eyes: periorbital swelling, ** immediate referral if extra-ocular muscle dysfunction or decreased visual acuity
Nose: mucopurulent secretion, erythema + swelling of the mucosa, anatomical anomalies (septal deviation/perforation/polyps, large turbinates), foreign body, dry crust
Mouth/Pharynx: postnatal drip, maxillary tooth tenderness (palpate maxillary floor from the palate)
Ears: concomitant OM in children
Neck: Lymphadenopathy
What are the RED FLAGS for sinusitis?
Persistent crust? (Wegner Granulomatosis)
Irregular surface
Diffusely hemorrhagic areas
Bleeding from minor trauma
What is the DDx for sinusitis
Allergic/fungal rhinosinusitis
Toothache, dental infection
Migraine, TMJ, Trigeminal neuralgia, herpes simplex/zoster
What investigations should be done for rhinosinusitis?
No evidence for culture or Xrays
CT if:
Complications of acute sinusitis (based on severs H/A, acute encephalopathy, facial swelling, cranial nerve palsies, proptosis of the eye)
Chronic sinusitis not responding to treatment
Severe presentation, diagnosis suspected but not clear
Consider allergy testing
Complications of rhinosinusitis
Periorbital/orbital cellulitis
Meningitis
Intracranial abscess
Intracranial venous thrombosis
Sepsis
Management of acute sinusitis
Analgesia
Irrigation of nasal cavity with saline
Inhalation of steam/warm compress
Short-duration topical/systemic decongestant (3 days)
Bacterial sinusitis:
- Mild to moderate: intranasal steroids x 3 days
If no improvement then AbX
Severe: intranasal steroid AND abx
Majority viral don’t need Abx
Assess at 7 days
Amoxicillin
Amox-clav
Etc
Management of chronic Rhinosinusitis
Intranasal cortico + saline irrigation
No nasal polyps:
- Intranasal cortico
- Second line ATB
- Consider short course oral steroid or nasal saline rinse
Nasal polyps:
Intranasal cortico + oral steroids
If signs of bacterial infection (purulence or pain): Abx for 3 weeks
- Amoxicillin/Clav
- Clinda
Consider leukotriene receptor antagonist
Referral to ENT sinusitis
Anatomic anomalies
Severe pain, immunocompromised, fungal
> 4 episodes per year
Chronic sinusitis not responding to treatment
