Depart. Of Pulmonology & Critical Care Medicine R4 백승숙 Barbara J. Turner, Sankey Williams, Darren Taichman

What is acute sinusitis? Inflammation and infection in one or more of the paranasal sinuses Acute rhinosinusitis - symptoms involve both the nasal cavity and the sinuses It often occurs after a cold, when mucus gets trapped in inflamed sinuses and does not drain properly  bacterial growth, or rarely fungal growth Duration of symptoms – Acute < 4 weeks – Subacute 4 weeks ~ 12 weeks – Chronic > 12 weeks

What is the risk of acute sinusitis? Recent upper respiratory viral infection Age – Older persons ; weakened cartilage, dryness in the nasal passages – Young children ; colds and smaller nasal and sinus passages Smoke and other air pollutants Air travel and changes in atmospheric pressure Swimming - chlorine Asthma and allergies - recurrent or chronic symptoms Dental disease - dental abscesses, periodontal infection Hospitalization - head injuries, insertion of tubes, mechanical ventilators

Risk facters Other medical conditions – AIDS and poorly controlled diabetes ; invasive fungal infections (eg, mucormycosis, zygomycosis) – Autoimmune disease - Wegener granulomatosis – Ciliary dysfunction - cystic fibrosis, Kartagener syndrome – Structural abnormalities or facial injuries - deviated septum, nasal polyps – Pregnancy

Diagnosis Acute sinusitis is diagnosed based on the history and physical examination Gold standard test - culture of the aspirate from an antral puncture The history – Duration of symptoms – Allergic rhinitis, systemic diseases, trauma, airplane travel, tobacco use, exposure to environmental toxins, anatomical abnormalities 2 primary symptoms – Purulent rhinorrhea (sensitivity 72%, specificity 52%) – Facial pressure or pain (sensitivity of 52%, specificity 48%)

The physical examination – Checking for swollen turbinates, purulent rhinorrhea, nasal polyps – Local sinus pain when bending over – Oropharyngeal red streak A Red Streak in the Lateral Recess of the Oropharynx Predicts Acute Sinusitis Colin Thomas, Vitali Aizin J GEN INTERN MED 2006 Diagnosis

Establishing the duration of symptoms is necessary to guide proper treatment and management Diagnosis

Imaging study is not typically required in the routine management of uncomplicated sinusitis – Rhinosinusitis symptoms lasting at least 7 to 10 days – Hx. of recurrent symptoms or nonresponse to multiple courses of antibiotics – Differential diagnosis (eg, anatomical abnormalities) Sinus radiography - sinus fluid or opacity, mucous membrane thickening CT and MRI - local spread or intracranial complications Diagnosis

Usually, no laboratory tests are needed to diagnose acute sinusitis – Do not respond to treatment or get worse Sinus puncture Transnasal endoscopic culture Nasal culture (direct swab) Diagnosis

What organisms can cause acute sinusitis? The predominant isolates – Streptococcus pneumonia and Haemophilus influenzae With recent pneumococcal vaccination  relative increase in H. Influenzae More Moraxella catarrhalis, especially in children and young adults More Streptococcus pyogenes Resistant to penicillins – Production of β -lactamase ; H. influenzae, M. catarrhalis, S. aureus, Fusobacterium spp., and Prevotella spp. – Changes in the penicillin-binding protein ; S. pneumoniae Acute fungal sinusitis - Aspergillus or Mucor species

Most cases of suspected sinusitis will resolve without antibiotic therapy Nondrug measures – Steam inhalation, hydration, and sinus irrigation Treatment

Nasal irrigation

Widespread prescribing of antibiotics – Increased costs of care – Promotion of drug-resistant strains of common respiratory Antibiotic therapy – Significantly lower risk for clinical failure at 7 to 15 days – Benefit disappeared with longer follow-up & Incresed adverse effects Treatment Acute bacterial sinusitis vs. Prolonged viral URI - High likelihood of bacterial sinusitis - Symptomatic Tx. fails in low-probability cases

Amoxicillin – First-line agent, 7 ~ 14 days (Data are limited on optimum duration) – Not improve after 3 to 5 days ; alternative antibiotic Doxycycline – Covers β -lactamase–producing strains of H. influenzae, M. catarrhalis Trimethoprim–sulfamethoxazole – Pneumococcal resistance rates ; 24% – Failure to respond after 5 days ; prompt reconsideration of therapy Cephalosporins – Second-generation cephalosporins, such as cefpodoxime – Minor side effects, mostly gastrointestinal (10 ~20%) Treatment

Nonantibiotic drugs - restore normal sinus environment and function – In patients with a low probability of bacterial disease - initial therapy – In patients who have been prescribed antibiotics - relieve symptoms Over-the-counter pain medications – Reduce sinusitis related congestion and discomfort Evidence on the effect of herbal remedies is very limited Treatment

Serious complications of acute bacterial sinusitis are rare when the infection is managed properly Serious complications of acute bacterial sinusitis – Intracranial complications - meningitis, brain abscess – Intraorbital complications - Periorbital and orbital cellulitis, blindness – Acute exacerbate of asthma Complications

Recurrent acute sinusitis Re-evaluation – Symptoms persist for several weeks – New or worsening symptoms develop – Symptoms suggestive of serious complications Persistent fever, sinus tenderness, purulent discharge, changes in mental status or vision Allergic inflammation, anatomic variation, cystic fibrosis, ciliary dyskinesia, immunocompromised state, presence of complications Antibiotic resistance

Practice Improvement The American College of Chest Physicians (ACCP) Expert Panel, 2006 – Patients with acute URI, the diagnosis of bacterial sinusitis should not be made during the first week of symptoms The American Academy of Otolaryngology and Head and Neck Surgery Foundation, 2007 – Symptoms worsen or do not improve by 7 days after management Reevaluate the diagnosis and consider other causes of illness – Acute bacterial sinusitis is confirmed Initially managed with observation Change the prescribed antibiotic

Practice Improvement The Joint Council of Allergy, Asthma, and Immunology, 2005 – Fungi are increasingly being recognized as a factor in chronic sinusitis Guidelines from the British National Institute for Health and Clinical Excellence – “No antibiotic or delayed antibiotic strategy” Agency for Healthcare Research and Quality – Newer antibiotics vs. Older, less expensive antibiotics