Other Causes of Rhinosinusitis

1
Other Causes of Rhinosinusitis
Hypertrophic Turbinates of Pregnancy
Septal Perforation of Cocaine Abuse
2
Potential Diagnostic Modalities
3
Physical Examination for Rhinosinusitis - Nasal
Endoscopy

• Bluish turbinates
• Pus at ostiomeatal area
• Polyp formation
• Septal deflections
• Concha bullosa
• Paradoxical turbinates
• Other abnormalities

4
Diagnostic Nasal Endoscopy Can Be Performed with
Rigid (0 or 30 degree) orFlexible Endoscopes
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Endoscopic Nasal Examination
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Posterior Septal Deviation Difficult to
Visualize by Anterior Rhinoscopy

• Septal (vomer) spur impinging not only on nasal
  airway, but protruding into the hiatus
  semilunaris to impede drainage from the
  ostiomeatal region

Middle turbinate
Uncinate
Vomer spur
Courtesy of H Stammberger
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Endoscopic view of middle meatal polyp that has
caused recurrent acute rhinosinusitis
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Concha Bullosa that Deviates Septum, Impinging
on Ostiomeatal Regions note contralateral Agger
Nasi cell
Concha
Courtesy of Karl Storz Co., Germany
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Purulent Drainage in Middle Meatus from Ethmoid /
Maxillary Infection
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Waters View of Unilateral Maxillary Sinusitis(L
cheek pain nasal congestion purulent
discharge RS, without need for X-ray)
L
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Plain Sinus Radiography

• Plain films can document acute maxillary, frontal
  or sphenoid RS, but utility is limited as the
  ethmoids, the most commonly infected sinuses, are
  not well visualized
• Plain films may have a role in following the
  progress of infection response to treatment,
  but only if baseline films were obtained
• Air-fluid levels documented on plain films during
  prior episodes of RS merit proceeding directly to
  nasal endoscopy CT scan
• Plain films are not recommended in chronic RS

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Coronal CT through Ostiomeatal Complex, with
Maxillary, Anterior Ethmoid and Lower Frontal
Sinuses Visible (most valuable single CT cut)
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CT Scans for Rhinosinusitis

• Should not be used as the sole diagnostic
  criteria
• Indicated for
• questions of diagnosis /or therapy
• strong history not responding to therapy
• prior to sinus surgery
• Timing of CT Scan
• in chronic RS, after 4 weeks or more of
  appropriate therapy
• in recurrent acute RS, in search of origin of
  problem
• in acute disease, if extrasinus spread of
  infection note in acute viral URIs that 87 of
  sinus CTs are positive, 21 remain so 2 weeks
  after clinical resolution (Gwaltney J et al NEJM
  33025-30, 1994)

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Proven Therapies for Bacterial RS include
Hydration Antibiotics, Possibly with
Decongestants /or Expectorants, but Many Other
Therapies are Advocated by Practitioners of
Alternative Medicine, OTC Drug Manufacturers,
etc.
Charleston, S.C. News and Courier - 1999
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Medical Management of Acute Bacterial RS

• Oral Hydration, Saline Sprays, Humidification
• Antibiotics (5-14 days, depending on antibiotic
  sympts.)
• Topical Decongestants (neosynephrine,
  oxymetazoline) for lt 5 days Oral Decongestants
  (pseudoephedrine)
• Mucolytics (guaiafenesin)
• ? Oral Antihistamines (only newer, non-sedating
  agents do not thicken secretions) Topical
  Anticholinergics or Antihistamines (same concern
  as above, though no sinus cavity penetration)
• ? Nasal Steroid Sprays (can diminish edema in
  ostiomeatal region)

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Microbiology of Acute Bacterial Rhinosinusitis
(Adults)
Sinus Allergy Health Partnership Guidelines for
Treatment of Acute Bacterial Sinusitis.
Otolaryngol Head Neck Surg 2004
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Microbiology of Acute Bacterial Rhinosinusitis
(Children)
Otolaryngol Head Neck Surg 2004130(1)S1S45.
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Signs / Symptoms of Acute Rhinosinusitis in an
Adult
Symptomatic Therapy, Hydration Observation
If S/S begin to wane in 5-7 days, continue
observation as likely a viral URI
If S/S worsen after 5 days, last gt 10 days, or
are out of proportion to viral URI
For community-acquired infection in healthy
patient, high dose amoxicillin for 7-14 days
For the hospitalized, or with immune compromise,
chronic respiratory disease, diabetes, renal
failure, cystic fibrosis or recurrent RS treated
within prior 8 weeks
For those who fail to improve in 2-3 days
Broad spectrum B-lactamase resistant antibiotic
for 5-14 days
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Penicillin-nonsusceptible S. pneumoniae is
Frequently Cross-resistant toOther Classes of
Antibiotic




Resistant isolates ()
(n589)
(n2,756)
(n848)
Pen-S, MIC ?0.06 µg/mL Pen-I, MIC 0.12-1 µg/mL
Pen-R, MIC ?2 µg/mL

NCCLS breakpoints used
Hoban DJ, et al. Clin Inf Dis. 200032(suppl
2)S81-S93.


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Variation in Incidence of S pneumoniae
Resistance US in 2002 (n10,103)
North Central
North West
North East
South West
South Central
South East
Protekt
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Factors That Influence Clinical Outcome
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Antimicrobials for Rhinosinusitis - Adults

• Respiratory Quinolones (95)
• HD Amoxicillin / Clavulanate (94)
• Ceftriaxone (94)
• HD Amoxicillin (1.5-4 g/d) (90)
• Cefpodoxime proxetil (88)
• Cefuroxime axetil (85)
• Cefdinir (83)
• TMP/SMX (81)
• Doxycycline (79)
• Telithromycin (77)
• Macrolides (73)
• Placebo (47-62)

More effective
Less effective
SAHP. Otolaryngol Head Neck Surg. 2004130(1
Suppl)S1.