Rhinosinusitis and Sinusitis Flashcards
What is rhinosinusitis?
Inflammation in the nose and paranasal sinuses.
How does rhinosinusitis present?
Diagnosis based on having 2 or more symptoms of: nasal blockage/obstruction/congestion, nasal discharge, facial pain or pressure, reduction of loss of smell and endoscopic or CT findings.
Describe acute rhinosinusitis?
Common cold, almost always self-limiting, if lasting longer than 5 days can consider intranasal corticosteroids (fluticasone or mometasone). If symptoms worsen after 5 days then likely acute post-viral sinusitis.
Describe chronic rhinosinusitis?
Symptoms for >12 weeks. Can be with or without nasal polyps.
What are the common causes of chronic rhinosinusitis without polyps?
Causes without polyps • Allergy (see below) • Chronic bacterial infections • Ciliary impairment e.g. CF • Anatomical abnormalities e.g. septal deviation • Hormonal – pregnancy and hypothyroid • Trauma – nasal sinus fracture • Foreign body • Swimming and diving
Describe rhinosinusitis with polyps - when do they require further investigation?
With polyps – inflammatory polyps that cause a CRS representing the extreme end of the disease. Normally found bilaterally but don’t require biopsy unless suspicious. (All unilateral polyps require biopsy).
How is rhinosinusitis managed?
Intranasal corticosteroids and nasal saline irrigation are key to management. If no improvement after 4 weeks and endoscopic examination reveals moderate to severe disease, consider cultures and add long term antibiotics (>12 weeks).
Surgical – nasal polypectomy, functional endoscopic sinus surgery, septoplasty, reduction of inferior turbinates.
Describe the presentation of allergic rhinosinusitis
Seasonal symptoms and associated with hay fever. Other symptoms include sneezing, pruritis, nasal discharge and bilateral itchy eyes.
Strong association with Asthma.
What is seen on endoscopy for rhinosinusitis?
Endoscopy shows inflamed turbinates, pale mucosa and nasal polyps.
How is allergic rhinosinusitis classified?
Classified based on its impact on Asthma (ARIA)
Duration
Intermittent – symptoms < 4 days per week and less than 4 weeks
Persistent – symptoms < 4 days per week and more than 4 weeks.
What defines the severity of allergic rhinosinusitis
Severity
Mild – no change to normal life
Moderate to severe – impairment of daily activities
How should suspected allergic rhinosinusitis be investigated?
Skin prick tests to common triggers – pollens, moulds, house dust mites and animal epithelia
RAST blood test if skin prick not possible
What is the management of allergic rhinosinusitis?
Management is by avoidance of trigger, nasal saline irrigation and oral or intranasal antihistamines for prevention (preferably non-sedating such as oral loratadine and cetirizine or intranasal azelastine and olopatadine).
If moderate, severe, or persistent then intranasal corticosteroid sprays – beclomethasone.
Short course of prednisolone can help rapid resolution for example during exams.
What other causes of rhinorrhoea are there aside from acute, chronic and allergic rhinosinusitis?
Foreign body, CSF after head injury, bacteria, CF, pregnancy and decongestant overuse.
What other causes of congestion are there aside from acute, chronic and allergic rhinosinusitis?
Child – large adenoids, choanal atresia, foreign body and post nasal space tumour
Adult – deflected nasal septum, granuloma (from TB, syphilis or leprosy), topical vasoconstrictors and tricyclics.
What are nasal polyps?
Swelling of the nasal or sinus mucosa into the nasal cavity. Note nasal polyps are rare in children <10yrs – must rule out neoplasm, cystic fibrosis and meningocele.
What is the typical presentation of nasal polyps?
Typical presentation – male >40yrs, usually bilateral, middle meatus most common, watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth breathing, snoring and headaches.
How should nasal polyps be investigated?
Anterior rhinoscopy or nasal endoscopy showing pale and mobile mucosal nodules that are insensitive to gentle palpation. Compared with turbinates which are pink, mobile and sensitive.
Note unilateral polyps or bleeding require urgent investigation
How are nasal polyps managed?
Medical – topical steroid drops can shrink the polyp e.g. betamethasone for 2 weeks followed by fluticasone for 3 months. Consider long term antibiotics such as doxycycline. Note must advise how to give nose drops – head forward not back.
Surgical – endoscopic sinus surgery, only consider if maximal medical treatment fails and ongoing severe symptoms. Complications are rare but can include damage to the optic nerve. After surgery don’t blow nose until better and be wary epistaxis.
What differentials should be considered before a diagnosis of sinusitis can be made?
- Migraine
- TMJ dysfunction
- Dental pain
- Neuropathic pain
- Temporal arteritis
- Herpes zoster
How does sinusitis present?
Sinus/facial pain
Nasal congestion and discharge (if blood stained and late presentation think cancer)
Fever >38
Elevated inflammatory markers
Double sickening – worsening after initial milder phase of illness.
Unilateral predominance
What can lead to a bacterial sinusitis?
Mostly follow a viral infection
Direct spread from dental root, diving or swimming
Odd anatomy e.g. septal deviation, polyps
ITU causes – mechanical ventilation, recumbency and use of NG tubes
Which organisms are often involved in bacterial sinusitis?
Common organisms – S. pneumoniae, H influenza, S Aureus, Moraxella Catarrhalis and various fungi.
How should suspected bacterial sinusitis be investigated?
Clinical diagnosis
Examine nose for mucosal inflammation, oedema and nasal discharge
CT if recurrent or acute
Nasal endoscopy
How is sinusitis managed?
Acute/Single episode – 98% are viral and self-limiting taking 2.5 weeks to resolve so treat with simple analgesia, decongestants, and nasal saline irrigation
Intranasal corticosteroids if symptoms present for more than 10 days
Antibiotics if bacterial causes suspected – amoxicillin or doxycycline
Chronic – treat as above but send for imaging/surgery.
Surgery is endoscopic sinus surgery tailored to the particular sinus.
Cessation of smoking
What potential complications can occur in bacterial sinusitis?
Complications to be aware of orbital cellulitis/abscess (emergency), meningitis, cerebral abscess, cavernous sinus thrombosis and osteomyelitis.
What is Samter’s triad?
Samter’s triad – association between asthma, nasal polyps and aspirin sensitivity
