Sinusitis Flashcards
Explain the paranasal sinuses
4 symmetrical air-filled spaces
Lined by ciliated, columnar epithelium
Interconnected thru small tubular openings (sinus ostia)
All drain into the osteomeatal complex which drains into the nasal cavity
What are the 4 sinuses called?
Ethmoidal, maxillary, Sphenoidal, Frontal
What does proper function of the sinuses involve?
Mucus that is of appropriate viscosity, composition and volume
Normal mucociliary flow
Open ostia to allow for adequate drainage and air flow
Maxillary sinus features drainage against gravity
What is sinusitis?
Inflammation of the mucous membrane lining the paranasal sinuses
Best called rhinosinusitis
Who does sinusitis affect? What are the root causes of sinusitis?
Adults and kids
Can be allergic, viral, or fungal
What are the different types of sinusitis?
Acute - new infxn less than 4 weeks in duration (may be divided in to severe and non-severe
Subacute - lasting 4-12 weeks
Chronic - Sx lasting 12+ weeks
Recurrent - 3 or more episodes per year
What is responsible for the development of sinusitis?
Blockage of inflammation of the osteomeatal complex
Obstruction interferes with mucociliary clearance
Tubes are connected -> URTI commonly results in sinus inflammation
What occurs when drainage and ventilation of the sinuses is compromised?
pH decreases
Oxygen content decreases
Cilia less functional
Mucosal lining damaged
Ultimately, leading to greater susceptibility to infxn
What are the predisposing/risk factors of sinusitis?
Immune deficiencies
Foreign bodies - things being stuck
Fractured nose
Polyps
Allergies/asthma
Dental infxn
Explain the early phase of sinusitis
Viral infxn usually lasting up to 10 days
May originated from cold
Mostly rhinovirus, adenovirus, influenza and parainfluenza viruses
Explain the types of organisms that present with sinusitis over time
Viral - 8-10days
Aerobes - 10 days to over 3 months
Anaerobes - Before 3 months and continues
*See slide 15 chart
True or False: Viral rhinovirus is much more common than bacterial sinusitis
True
What are the signs and symptoms of sinusitis?
Mucopurulent nasal discharge (colour of discharge means nothing)
Nasal congestion/obstruction
Tenderness over sinus/facial pain
- Sometimes fever, headache, cough
How long does it take for acute viral sinusitis sx to improve?
1 week
True or False: Sinusitis is rare in children under 9 years old
True, due to undeveloped sinuses
The 2013 pediatric guidelines for bacterial sinusitis presentation
Common: Persistent sx of nasal discharge, daytime cough, or both for at least 10 days without improvement or new onset of sx after initial improvement
Severe: Severe sx for at least 3 days in febrile child (39C) who has purulent nasal discharge and seem ill
Explain the sx related to the common cold and the duration of time that it takes to resolve sx
Sore throat and sneezing: resolve day 3 to 6
Fever, malaise, myalgia: resolve day 6 to 8
Cough, nasal discharge and nasal obstruction may last weeks (25% have at 14 days)
What is the diagnosis of bacterial sinusitis based on?
Signs and sx along with patient history and physical exam
if sx beyond 10 days, then could be bacterial
Do nasal aspirates and transillumination helpful in diagnosis of sinusitis? How about X-rays and Ct scans?
not very helpful
used to see abnormalities or complications (viruses prod same abnormalities as bacteria)
Sinusitis is mainly viral. What are the bacterial species responsible for bacterial sinusitis?
Most common to least common
S.Pneumoniae, H. influenzae, M. catarrhalis, S.aureus, S.pyogenes (last two - GAS)
What species of organisms are you expected to see in immunocompromised or hospital acquired sinusitis?
Gram -ve or fungal sp
Do we know if anaerobes are a cause of chronic sinusitis or just inhabiting the area?
No
When will most patients get better from sinusitis?
within 10 days
What are the complications of sinusitis?
Abscess, cellulitis and osteomyelitis
Spread of infxn to the nervous system
What are the non-pharmacological symptomatic relief options?
Steam inhalation
Fluids -> want to keep mucus moving
Apply warm face cloth or heat of some kind
Avoid irritants such as smoke (allergies)
Saline drops or irrigation
What are the pharmacological treatment options?
Analgesic
Oral or topical decongestants - no evidence of benefit
Intranasal steroid (better in chronic cases only)
Avoid 1st gen Anti-He (dry out the mucosa, we want to get rid of the mucus)
Oral steroids (reduce edema and inflammation, little evidence for role in acute)
When are people who are not given ABs improve?
80% improve in two weeks
AB only provide a small benefit compared to placebo
What should pharmacists do for deciding antibiotic treatment?
Wait a week to 10 days after it first starts, then decided if ABs are needed
What are the goals of AB treatment?
Restore/improve sinus fxn
Prevent intracranial complications
Eradicate pathogen
What is the first line option for acute bacterial sinusitis? Provide the dosing
Amoxicillin 500mg-1000mg TID x 5-10d (5 days is sufficient)
What are the second line AB options for acute bacterial sinusitis?
Amox/clav 500 mg TID or 875 BID
2nd gen cephalosporins
Doxycycline 100mg BID day 1, then 100mg OD OR 200mg day 1, then 100mg BID
Clarithromycin or azithromycin
What are the third line option for acute bacterial sinusitis?
Quinolones
Levofloxacin 500mg OD
Moxifloxacin 400mg OD
5-10 days (again, 5 days is sufficient)
What is the first line AB tx for kids?
Amoxicillin 40-90mg/kg/day BID or TID (max 3g/day)
duration 10 days!
What is the second line AB tx for kids?
Amox/clav 40-90mg/kg/day divided BID
Cefuroxime 30-40mg/kg/day divided BID
Cefprozil 30mg//kg/day divided BID
duration 10 days!
What is the third line AB tx for kids?
Clarithromycin 15mg/kg/day divided BID
Azithromycin 10mg/kg/day first day, then 5mg/kg OD x4 days
(TMP/SMX 5-10 mg/kg/day TMP divided BID)
Explain AB tx for chronic cases. What is the chronic definition? What organisms might you see? What are good AB choices for chronic? How long do you treat for?
If the disease persists for 3 months
See more S. aureus and anaerobes
Amoxicillin/clavulanate or clindamycin
Treat for 3 weeks
