Grand Rounds Rebecca Burton-MacLeod R4, Emergency Medicine February 1 st, 2007

Case 32M previously healthy presents to ED c/o headache. Frontal x 6days. Worsens when he chews. No signif relief with tylenol. Low-grade fever. Recent URTI symptoms (~2wks ago). No hx of headaches. 32M previously healthy presents to ED c/o headache. Frontal x 6days. Worsens when he chews. No signif relief with tylenol. Low-grade fever. Recent URTI symptoms (~2wks ago). No hx of headaches. Exam unremarkable. T 38.1C Exam unremarkable. T 38.1C Any thoughts ? Any thoughts ?

Acute Sinusitis: Diagnostic Dilemmas ?

Overview Introduction to sinusitis Introduction to sinusitis Diagnosis? Diagnosis? Imaging? Imaging? Who to be worried about? Who to be worried about?

Anatomy

Incidence Sinus inflammation occurs in 90% of individuals with the “common cold” Sinus inflammation occurs in 90% of individuals with the “common cold” Bacterial infection complicates ~2% of these cases Bacterial infection complicates ~2% of these cases Almost all cases follow a viral URTI; occasionally a complication of allergic rhinitis Almost all cases follow a viral URTI; occasionally a complication of allergic rhinitis The usual ENT culprits—Strep pneumoniae, H flu, Moraxella catarhallis, Staph aureus The usual ENT culprits—Strep pneumoniae, H flu, Moraxella catarhallis, Staph aureus

Classification Acute: Acute: –Symptoms up to 4wks Subacute: Subacute: –Symptoms from 4- 12wks Chronic: Chronic: –Symptoms >12wks Recurrent acute: Recurrent acute: –4+ episodes in one year, each lasting >7days

Pathophysiology Ciliated pseudostratified columnar epithelium Ciliated pseudostratified columnar epithelium –Secretes mucous which traps particles –Expelled into nasal airway through sinus ostia Immunologic host defenses in sinuses creates normally sterile environment Immunologic host defenses in sinuses creates normally sterile environment Obstruction of ostia causes stagnant environment allowing bacterial overgrowth Obstruction of ostia causes stagnant environment allowing bacterial overgrowth

Diagnosis American Academy of Otolaryngology-Head and Neck Surgery

Physical examination ? Anterior rhinoscopy with nasal speculum Anterior rhinoscopy with nasal speculum Visualization of purulent nasal discharge Visualization of purulent nasal discharge Sinus tenderness Sinus tenderness Transillumination of sinuses Transillumination of sinuses

Exam findings ? 3/14 pts later diagnosed with acute sinusitis had any evidence of purulent discharge 3/14 pts later diagnosed with acute sinusitis had any evidence of purulent discharge Rhinoscopy only allows visualization of anterior nasal cavities Rhinoscopy only allows visualization of anterior nasal cavities

Transillumination? Transillumination— sensitivity 73% specificity 54% Transillumination— sensitivity 73% specificity 54%

Exam findings ? Comparison of sinus tenderness with other systemic tenderness Comparison of sinus tenderness with other systemic tenderness Sinus pain at lower cutaneous pressures if rhinosinusitis Sinus pain at lower cutaneous pressures if rhinosinusitis However, chronic fatigue s/o pts had 44% lower thresholds for all locations of tenderness (including sinus) However, chronic fatigue s/o pts had 44% lower thresholds for all locations of tenderness (including sinus)

Imaging options XRay XRay CT CT MRI MRI U/S U/S

Xray 3 standard views: 3 standard views: –Caldwell (AP) –Waters (occipito-mental) –Lateral

Xray diagnosis Air-fluid levels Air-fluid levels Sinus opacity Sinus opacity Marked mucosal thickening (>6mm) Marked mucosal thickening (>6mm)

Xray ?low sensitivity and specificity vs. gold standard ?low sensitivity and specificity vs. gold standard Engels EA et al. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epi Unable to visualize ethmoid sinuses well in any of 3 views (20% of pts have isolated ethmoid sinus infections) Unable to visualize ethmoid sinuses well in any of 3 views (20% of pts have isolated ethmoid sinus infections) Slavin RG et al. The diagnosis and management of sinusitis: a practice parameter update. J Allerg Clin Immunol Cannot define extent of disease Cannot define extent of disease Zinreich JS. Functional anatomy and CT imaging of paranasal sinuses. Am J Med Sci

Comparing XR, U/S, clinical exam Meta-analysis of studies comparing diagnostic modes for acute maxillary sinusitis Meta-analysis of studies comparing diagnostic modes for acute maxillary sinusitis Sinus puncture used as gold standard Sinus puncture used as gold standard XR: XR: –N =996 pts; 7 studies –Weighted mean sensitivity 87%, specificity 89% U/S: U/S: –N=940 pts; 7 studies –Weighted mean sensitivity 85%, specificity 82% Clinical exam: Clinical exam: –N=245 pts; 2 studies –Weighted mean sensitivity 69%, specificity 79% Varonen H et al. Comparison of U/S, XR, and clinical exam in the diagnosis of acute maxillary sinusitis: a systematic review. J Clin Epi

CT Indications: Indications: –Severe unilateral maxillary pain –Facial swelling –Fever –Changes in mental status –Unresponsive to abx treatment Limitations: Limitations: –Lack of correlation b/w sinus symptoms and CT findings –Unable to differentiate viral from bacterial sinusitis –High frequency of abnormal scans in asymptomatic pts Piccirillo JF. Acute bacterial sinusitis. NEJM

CT specificity 87% of pts with common cold showed changes in sinuses on CT 87% of pts with common cold showed changes in sinuses on CT ?differentiate b/w viral and bacterial causes of rhinosinusitis ?differentiate b/w viral and bacterial causes of rhinosinusitis Gwaltney JM Jr et al. CT study of the common cold. NEJM

Correlation b/w symptoms and CT findings N=200 consecutive pts referred for CT for sinus pain N=200 consecutive pts referred for CT for sinus pain R temple/forehead most commonly reported site of maximal pain R temple/forehead most commonly reported site of maximal pain On CT, maxillary sinus most frequently involved On CT, maxillary sinus most frequently involved Bivariate analysis showed no relationship b/w symptoms and finding on CT Bivariate analysis showed no relationship b/w symptoms and finding on CT Pts with abnormal CT reported 5.45 sites of facial pain vs sites on pts with normal CT Pts with abnormal CT reported 5.45 sites of facial pain vs sites on pts with normal CT Sikha P et al. Correlation between presumed sinusitis-induced pain and paranasal sinus CT findings. Ann Allerg Asthma Immunol

Canada vs. US facial pain and CT findings N=51pts; 27 were recruited in Edmonton N=51pts; 27 were recruited in Edmonton Questionnaire completed prior to CT to r/o rhinosinusitis Questionnaire completed prior to CT to r/o rhinosinusitis No correlation b/w pain severity and disease severity on CT (p>0.05) No correlation b/w pain severity and disease severity on CT (p>0.05) Mean pain score for US pts 7.3 vs. 5.2 for Canadian pts Mean pain score for US pts 7.3 vs. 5.2 for Canadian pts Canadian pts had more severe disease on CT while reporting less pain (p=0.004) Canadian pts had more severe disease on CT while reporting less pain (p=0.004) Shields G et al. Correlation between facial pain or headache and CT in rhinosinusitis in Canadian and US subjects. Laryngoscope

Comparing CT and XR N=47 consecutive pts over 6mos N=47 consecutive pts over 6mos XR and CT on the same day XR and CT on the same day Calculated sensitivity of XR for each sinus: Calculated sensitivity of XR for each sinus: –Maxillary 80% –Ethmoid 41% –Frontal 39 % –Sphenoid 47% Specificity % Specificity % Time spent performing each study (5-9min for CT); half of time spent doing XR Time spent performing each study (5-9min for CT); half of time spent doing XR Aalokken TM. Conventional sinus XR compared with CT in the diagnosis of acute sinusitis. DentoMaxilloFacial Radiog

Cost-effectiveness Model to examine different strategies for treatment of acute sinusitis: Model to examine different strategies for treatment of acute sinusitis: –Use of clinical criteria-guided treatment was cost- effective in most cases –Sinus XR-guided treatment not cost-effective for initial treatment Balk EM et al. Strategies for diagnosing and treating suspected acute bacterial sinusitis: a cost-effectiveness analysis. J Gen Intern Med Consensus statement from variety of N. Am experts stated radiography not warranted when likelihood of acute sinusitis is HIGH or LOW but useful when diagnosis in doubt Consensus statement from variety of N. Am experts stated radiography not warranted when likelihood of acute sinusitis is HIGH or LOW but useful when diagnosis in doubt Anzai Y et al. Imaging evaluation of sinusitis: diagnostic performance and impact on health outcome. Neuroimag Clin N Am

Bottom-line Xrays—inadequate to aid in diagnosis Xrays—inadequate to aid in diagnosis CT—useful if confirmation of diagnosis is indicated as views all sinuses and looks for potential complications CT—useful if confirmation of diagnosis is indicated as views all sinuses and looks for potential complications MRI—unlikely to add information to CT MRI—unlikely to add information to CT U/S—not used in N. Am for diagnosis of sinusitis U/S—not used in N. Am for diagnosis of sinusitis

So, what’s the rush in diagnosing…

Complications Local: Local: Intracranial: Intracranial: –Meningitis –Abscess –Pott’s puffy tumor –Sagittal sinus thrombosis –Cavernous sinus thrombosis Orbital complications: Orbital complications: –Cellulitis –Abscess Distant: Distant: Pulmonary (exacerbations of): Pulmonary (exacerbations of): –Asthma –Bronchitis –COPD –CF Systemic: Systemic: –Sepsis –Toxic shock s/o

Intracranial complications

Who to watch for… Majority are young adult males Majority are young adult males Male:Female is 2:1 up to 4.5:1 Male:Female is 2:1 up to 4.5:1 Mean age 24 years Mean age 24 years Average from onset of URTI symptoms to complication is 15days Average from onset of URTI symptoms to complication is 15days Jones et al. The intracranial complications of rhinosinusitis: can they be prevented? Laryngoscope Reported rate from hospitalized pts is % (likely over-estimated) Reported rate from hospitalized pts is % (likely over-estimated) Osborn MK et al. Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis

Common s/s Headache, fever, nuchal rigidity, vomiting, behaviour changes, seizures Headache, fever, nuchal rigidity, vomiting, behaviour changes, seizures Younis et al. Sinusitis complicated by meningitis: current management. Laryngoscope Headache, fever, lethargy, focal neuro deficit, seizures Headache, fever, lethargy, focal neuro deficit, seizures Lang EE et al. Intracranial complications of acute frontal sinusitis. Clin Otolarygnol Fever, altered LOC, focal neuro findings, orbital findings, also “silent” (asymptomatic) Fever, altered LOC, focal neuro findings, orbital findings, also “silent” (asymptomatic) Osborn MK et al. Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis

Investigations Labwork—not useful Labwork—not useful –30% of pts have normal WBC –ESR and CRP may be elevated XR—not useful XR—not useful CT—diagnostic tool of choice (with contrast) CT—diagnostic tool of choice (with contrast) LP—only perform after CT! LP—only perform after CT! Jones et al. The intracranial complications of rhinosinusitis: can they be prevented? Laryngo Younis et al. Sinusitis complicated by meningitis: current management. Laryngo

Which sinuses? Review of 82 pts over 15years admitted with sinusitis complications: Review of 82 pts over 15years admitted with sinusitis complications: –With meningitis: ethmoid and sphenoid sinuses involved in all 21pts (may be unilateral) –With abscesses: pansinusitis most common finding (16 pts); frontal sinuses most frequently involved (11pts) Younis et al. Intracranial complications of sinusitis: a 15 year review of 39 cases. ENT Journal 2002.

Treatment 3 rd generation cephalosporin and metronidazole 3 rd generation cephalosporin and metronidazole Tailored once antimicrobial identification and susceptability identified Tailored once antimicrobial identification and susceptability identified

Outcomes Younis et al. Sinusitis complicated by meningitis: current management. Laryngo 2001.

Local opinions “possible ENT consult warranted if evidence of frontal/sphenoid sinusitis and pt toxic” “possible ENT consult warranted if evidence of frontal/sphenoid sinusitis and pt toxic” “only admit if evidence of complications” “only admit if evidence of complications” Reassess in few days if no improvement despite treatment Reassess in few days if no improvement despite treatment Dr’s. Bosch, Hui, Park (ENT surgeons)

Questions ?