Sinusitis Flashcards by Jordan Cyr

Describe the anatomy of the sinuses.

4 symmetrical air-filled cavities called paransal sinuses
lined by ciliated, columnar epithelium
interconnected through small tubular openings (sinus ostia)
all drain into the osteomeatal complex which drains into the nasal cavity

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What are the four sinuses?

frontal
ethmoidal
maxillary
sphenoidal

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Describe what would be occurring during normal function of the sinuses.

mucus of appropriate viscosity, composition, and volume
normal mucociliary flow
open ostia to allow for adequate drainage and air flow

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Which sinus drains against gravity, making functioning cilia very important?

maxillary sinus

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What is sinusitis?

inflammation of the mucous membrane lining the paranasal sinuses

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What is sinusitis best called?

rhinosinusitis
-nasal mucosa is always involved

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True or false: sinusitis is only allergic and viral in nature

false
can be allergic, viral, bacterial, or fungal

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What are the four types of sinusitis?

acute: new infection <4 weeks in duration
subacute: lasting 4-12 weeks
chronic: symptoms lasting >12 weeks
recurrent: 3 or more episodes in a year

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What is responsible for the development of sinusitis?

blockage or inflammation of the osteomeatal complex
-the obstruction interferes with mucociliary clearance
-all the tubes are connected, URTI commonly results in sinus
inflammation

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What happens once drainage and ventilation of the sinuses is compromised?

pH is decreased
oxygen content decreases
cilia is less functional
mucosal lining is damaged
MORE SUSCEPTIBLE TO INFECTION

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What are the risk factors for sinusitis?

immune deficiencies
foreign bodies
fractured nose
polyps
allergies/asthma
dental infection

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What is the most common cause of early phase sinusitis?

viral infection lasting up to 10 days
-may originate from a cold
-mostly rhinovirus, adenovirus, influenza, and parainfluenza

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What percentage of viral sinusitis progress to bacterial infections?

0.5-2%
viral rhinosinusitis is 20-200x more common than bacterial sinusitis

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What are the signs and symptoms of sinusitis?

mucopurulent discharge
nasal congestion/obstruction
tenderness over sinus/facial pain
sometimes fever, headache, and cough

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How long does it take for acute viral sinusitis tend to improve?

1 week
most patients well within 10 days

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Which group of patients would it be rare to see sinusitis in?

children <9yo
-undeveloped sinuses

What is the presentation of bacterial sinusitis in children?

persistent symptoms of URTI without improvement after 10-14 days
WITH BOTH: purulent discharge AND continued unwell state
+/- fever, cough, irritability, lethargy, facial pain

What is the severe presentation of bacterial sinusitis in children?

severely ill child
with both: purulent discharge AND fever >39 C (non-responsive to antipyretics)
usually associated with: cough, headache, facial swelling, sinus tenderness
LESS COMMON, SUSPECT COMPLICATIONS

What is the presentation of bacterial sinusitis in adolescents/adults?

persistent symptoms of URTI without improvement after 10-14 days or worsening after 5 days
WITH BOTH: nasal congestion/purulent discharge AND facial pain
+/- fever, molar swelling, facial swelling

What are other concurrent symptoms of bacterial sinusitis in adolescents/adults?

headache
bad breath
fatigue
cough
facial pain worse on bending forward
ear pain/pressure
loss of smell

True or false: green nasal discharge is predictive of bacterial sinusitis

false
color and nature of nasal discharge does not predict bacterial infection

How is sinusitis diagnosed?

mostly on signs and symptoms
-along with patient history and physical exam
-symptoms >10d=bacterial should be considered
nasal aspirates: not very helpful
transillumination of maxillary+frontal sinus: not helpful
X-ray, CT scan: used to see abnormalities or complications
-viruses produce same abnormalities as bacteria

What is the microbiology of sinusitis?

frequently viral
in bacterial sinusitis:
-S. pneumoniae (30-60%)
-H. influenzae (21-23%)
-M. catarrhalis (2-19%; 20% in kids)
-may also be S. aureus, S. pyogenes

Which organisms would be expected to cause sinusitis in immunocompromised or hospital acquired?

gram negative
fungus

True or false: anaerobes are the cause of chronic sinusitis

false unknown if they are cause of chronic sinusitis or just inhabiting the area maybe chronic sinusitis is just an inflammatory disease without chronic infection

What are the complications of sinusitis?

complications are rare but include: -abscess -cellulitis -osteomyelitis -spread of infection of nervous system

What are some non-pharmacological symptomatic reliefs of sinusitis?

steam inhalation fluids apply warm face cloth or heat of some kind avoid irritants such as smoke saline drops or irrigation

What is the pharmacological symptomatic relief for sinusitis?

ANALGESICS oral or topical decongestants (no evidence of benefit) intranasal steroids (not as beneficial in acute) avoid 1st gen antihistamines oral steroids: reduce edema and inflammation but little evidence of benefit

Which approach should be used for sinusitis, in regards to antibiotic therapy?

wait and see -if still bothersome at a week-10 days after onset and meet clinical criteria then antibiotics may be warranted -this strategy results in a 90% cure rate after 1 week of treatment with antibiotics

What are the goals of therapy with antibiotics when treating sinusitis?

restore/improve sinus function prevent intracranial complications eradicate pathogen

What is first line treatment for sinusitis in adults? What is the dosing of this therapy?

amoxicillin 500mg-1000mg TID x 5-10d -evidence that 5 days is sufficient

What are the second line treatment options for sinusitis in adults? What are the dosings of these therapies?

AmoxiClav 500mg TID or 875mg BID 2nd gen cephalosporin doxycycline 100mg BID day 1, then 100mg OD OR 200mg day 1, then 100mg BID clarithromycin or azithromycin

What are the third line treatment options for sinusitis in adults? What are the dosings of these therapies?

levofloxacin 500mg OD moxifloxacin 400mg OD *5-10 days*

What is first line treatment of sinusitis in kids? What is the dosing of this therapy?

amoxicillin 40-90mg/kg/d BID or TID 10 days max 3g/day

What is second line treatment of sinusitis in kids? What is the dosing of these therapies?

AmoxiClav 40-90mg/kg/d BID cefuroxime 30-40mg/kg/d BID30 cefprozil 30mg/kg/d BID *10 days*

What is third line treatment of sinusitis in kids? What is the dosing of these therapies?

clarithromycin 15mg/kg/d BID azithromycin 10mg/kg/d on first day, 5mg/kg/d x 4 days TMP/SMX 5-10mg/kg/d TMP divided BID

Which organisms may you see more of in chronic sinusitis?

S. aureus and anaerobes

What are the treatment options for chronic sinusitis? How long is therapy?

AmoxiClav or clindamycin 3 weeks