Acute sinusitis and rhinosinusitis

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Acute sinusitis and rhinosinusitis

• Natural history, pathogenesis, diagnosis,
  treatment

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Infectious agents causing sinusitis

• Viral agents rhinovirus, adenovirus, corona
  virus, respiratory syncytial virus, influenza
  virus, para-influenza virus
• Bacteria strep pneumonia, hemophilus
  influenza,Moraxella catarrhalis
• Fungi

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Other predisposing factors

• Allergies
• Nasal polyps
• Trauma with sinus ostial obstruction
• Displaced nasal septae interfering with drainage
  of sinus ostia
• Dental infection
• Nasogastric tubes
• Nasopharyngeal endotracheal tubes

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Viral sinusitis

• 31-87 show sinusitis by CT early in the course
  of viral colds
• Sinus punctures show no bacteria
• Antibiotics fail to alter rate of resolution
• About 2 of viral respiratory infections result
  in bacterial sinusitis

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Symptoms of II bacterial sinusitis

• Increasing symptoms 7-10 days
• Increasing facial pain.(maxillary or frontal)
• Persistent or worsening cough
• Purulent or bloody nasal discharge
• Pain in the upper teeth
• Fever , facial swelling, erythema

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Signs

• Tenderness to percussion
• Failure to transilluminate
• Fluid in sinuses on coronal CT (which has
  replaced sinus x rays)-not required unless
  patient fails 1-2 courses of antibiotics
• Sinus puncture for culture only reliable culture
  technique but not used clinically

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Treatment of viral rhinosinusitis

• 1st generation antihistamines
• NSAIDs
• Oral decongestant or antitussive prn
• Pseudoephedrine or Afrin or Duration nasal
  spray(4 days maximum for these)

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Antibiotic Rx for Bacterial Sinusitis

• Traditional guidelines amoxicillin, trimethoprim
  sulfamethoxazole,doxycycline 9
• Alternate approach (for possible resistance)
• Amoxicillin Clavulanate875/125 bid x7-10d.77
• Cefpodoxime 200 q. 12 hrs x 7-l0 days 75
• Cefdinir 600 daily x l0p days 88
• Fluoroquinalone levofloxacin 500/day or
  moxifloxacin 400/day x10 days 97
• Success rate 79 to 90 in different studies.

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Treatment of patient failing initial rx

• 2-4 weeks of a different antibiotic
• Inhaled corticosteroids( fluticasone)
• Sinus CT
• ENT referral
• Short courses of corticosteroids
• Consider endoscopic sinus surgery

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Fungal Sinusitis

• Allergic fungal sinusitis, often associated with
  asthma , atopy, nasal polyps
• Fungi non invasive10-20 aspergillus also brown
  pigmented fungi such as alternaria
• Type I IGE mediated hypersensitivity reaction
• Nasal polyps or deviated septum common

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Allergic fungal sinusitis

• Sinuses filled with allergic mucin
• Charcot Leyden Crystals
• Hyphae present in mucin on special stain
• Nasal polyps usually present
• Elevated eosinophil level or IGE levels common
• Rx endoscopic surgery, systemic steroids, then
  inhaled steroids

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Invasive fungal sinusitis

• Generally accompanies immune suppression
• Hematologic malignancy
• Bone marrow transplant patients
• Chemotherapy induced neutropenia
• Solid organ transplantation
• Diabetes mellitus
• HIV infection

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Invasive fungal sinusitis

• Aspergillus
• Fusarium
• Zygomycetes (Mucorales)
• Dermatiaceous molds
• Present with fever, severe facial pain,nasal
  congestion, epistaxis, changes in
  vision,mentation
• CT often shows orbital involvement or bony
  erosions or extension to globe, brain,cavernous
  sinus, or carotid artery

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Chronic invasive fungal sinusitis

• Chronic symptoms for months
• Visual change due to orbital invasion or brain
  involvement resulting in neurologic complaints
• CT mass, sinus thickening, bony erosion

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RX for invasive fungal sinusitis

• Amphotericin B or newer antifungal
• Surgical Rx
• Restoration of immunity if possible