1. Sinusitis: Assessment, Diagnosis and Treatment Sometimes It Is, Sometimes It’s Snot
Michael De Vito M.D.
Capital Region Otolaryngology Group
Albany, Troy, Clifton Park and Hudson

2. Introduction Sinusitis:
Affects 30 million individuals per year in the US
90% of patients will see their primary care physician
Accounts for 11.6 million visits to primary care physicians annually
Accounts for 9% of pediatric and 21% of adult antibiotic prescriptions

3. Anatomy

4. Anatomy

5. Sinus Drainage Pathways

6. Pathogenesis of Sinusitis

7. Classification of Sinusitis
Sinusitis is defined as an inflammation of the mucous membrane that lines the paranasal sinuses It is classified chronologically as: Acute Recurrent Acute Subacute Chronic Acute Exacerbation of Chronic

8. Acute Rhinosinusitis A New Infection That May Last Up To Four Weeks
Can Be Subdivided Symptomatically Into
Severe
Non-severe

9. Recurrent Acute Rhinosinusitis
Four or More Separate Episodes of Acute Sinusitis That Occur Within One Year

10. Subacute Rhinosinusitis
An Infection That Lasts Between Four to Twelve Weeks
Usually Represents a Transition From Acute To Chronic Infection

11. Chronic Rhinosinusitis
When Signs and Symptoms Last for More Than Twelve Weeks

12. Diagnosis of Sinusitis

13. Viral Versus Bacterial Rhinosinusitis
Viral Upper Respiratory Illnesses Occur:
3-8 per year in children
2-3 per year in adults
Gwaltney: (1996,1994)
Found 90% of CT Scans Showed Evidence of Sinus Involvement With Viral Rhinosinusitis

14. Viral Upper Respiratory Infection Course

15. Viral Versus Bacterial Rhinosinusitis
Difficult to Differentiate
Symptoms of Bacterial Sinusitis Worsen After Five Days
Bacterial Infections Persist For At Least Ten Days
Task Force On Rhinosinusitis Of The AAO-HNS
Diagnosis of Acute Sinusitis Depended On The Presence of :
Two Major Diagnostic Factors or
One Major Factor and Two Minor Factors

16. Diagnostic Predictive Factors of Sinusitis

18. Acute Sinusitis Definitions

19. Radiographic Imaging
Radiographic Imaging Should Not Be Used In Patients That Meet The Diagnostic Criteria of Acute Rhinosinusitis
Exceptions Include:
A Potential Complication of Sinusitis
An Alternative Diagnosis is Suspected

20. Symptomatic Treatment
Analgesics and Antipyretics for Pain and Fever
Topical or Systemic Decongestants for Symptomatic Relief
Neither have been proven to prevent a URI
from becoming ABRS
Topical Better Than Systemic for Congestion Relief
3 Day Maximum – Longer Rebound Concern
Systemic Steroids Have Shown No Effectiveness
Antihistamines Have No Studies As To Effectiveness

21. Symptomatic Treatment
Topical Steroid Sprays Have Shown Some Benefit
Industry studies and included antibiotics
Nasal Saline for Quality of Life Improvement
Decrease medication use for frequent ABRS
Guaifenesin
Insufficient evidence

22. Most Prevalent Pathogens in Adult Sinusitis
Other (4%)
Staphylococcus aureus
(0-8%)
Moraxella catarrhalis
(2-10%)
Streptococcus
pneumoniae (20-43%)
Anaerobes (0-9%)
Slide Objective:
To identify the most likely organisms causing sinusitis, highlighting the 2 main causative pathogens.
Speaker Notes:
S pneumoniae and H influenzae are the two most common bacterial isolates recovered from the maxillary sinuses of adult patients with ABS.2
As depicted in the graph above, S pneumoniae is isolated in approximately 20% to 43% and H influenzae in 22% to 35% of aspirates.1
Other common pathogens include M catarrhalis, streptococcal species, S aureus, and anaerobes.1
Optimal antibiotic therapy should be based on adequate coverage of anticipated bacteria.2
Moxifloxacin has potent activity against S pneumoniae, H influenzae, and M catarrhalis.1
References:
Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004; 130 (1 Suppl):1-45.
AAOHNS. Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg. 2007:137;S1-S31.
Streptococcus spp.
(3-9%)
Haemophilus influenzae
(22-35%)
Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004.
AAOHNS. Otolaryngol Head Neck Surg

23. Empiric Treatment in Children
Amoxocillin-clavulanate Rather Than Amoxocillin
Increasing prevalence of H. influenza in URIs in children
High prevalence of Beta-lactamase producing pathogens in ABRS
H. influenza and Moraxella catarrhalis
IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis

24. Antibiotic Regimen in Children

25. Starting Empiric Antibiotic Treatment
In Adults When Clinical Diagnosis Has Been Established By The Guidelines
Symptoms of rhinosinusits lasting more than 10 days
Severe symptoms or high fever and purulent nasal discharge or facial pain lasting 3-4 consecutive days at the onset of illness
Worsening of symptoms with fever, headache or increased nasal discharge at day 5-6 of a URI that were improving.
IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis

26. Antibiotic Regimen for Adults

27. Treatment of Penicillin Allergic Patients
Skin Testing to Confirm of Exclude Immediate Hypersensitivity
Adults:
Respiratory Floroquinolone
(Levofloxacin,Moxifloxacin)
Doxycycline
Macrolides or TMP/SMX
No Longer Recommended because of increased resistance of S. pneumonia and H. influenza

28. Children with Penicillin Allergy
Children with Type 1 Hypersensitivity:
Levofloxacin
FDA approved for use only after Anthrax Exposure
2523 Children Studied in the Pediatric Levaquin Study (Noel, 2007)
Well tolerated after 12 Months But
Musculoskeletal Events
1.9% vs. .79% at 2 months
2.9% vs.1.6% at 12 months
Probably Warranted with Type 1 sensitivity

29. Children with Non-Type 1
Third Generation Oral Cephalosporin:
Cefixime, Cefpodoxime
In Combination With Clindamycin

30. Duration of Therapy 5-7 Days Seems Appropriate
Most patients studied by sinus puncture had symptomatic improvement and bacteriological eradication within 72 hours of initiation of treatment
Treatment beyond 10 days for acute , uncomplicated patients seems excessive
Children Should Be Treated for Days
Studies still lacking to recommend less

31. Nonresponsive Patients
Patients Who Clinically Worsen After 72 Hours or
Fail to Improve After 3-5 Days of Empiric Therapy:
Resistant Pathogens
Noninfectious Etiology
Structural Abnormalities
CT of MRI
Noninfectious causes of suppurative complications
Sinus or Meatal Cultures
Careful Clinical Assessment

32. Sinus Cultures Direct Sinus Aspiration :
Most Accurate but Invasive , Not Well Tolerated
Middle Meatal Cultures:
Benninger (2006)
81% sensitivity, 91% specificity,
83% predictive value
Nasopharyngeal Swabs:
Unreliable

33. Allergy Evaluation Chronic Sinusitis And Allergy: 40-80% of Adults
25-31% Young Adults
Should Be Considered In:
Chronic Rhinosinusitis
Recurrent Acute Rhinosinusitis
Skin Testing As The Preferred Testing Method

34. Immunodeficiency
Patients with Chronic Rhinosinusits or Recurrent Acute Sinusitis
Failure of Aggressive Medical Therapy or Persistent Purulent Infection
Most Common Disorders:
Selective IgA Deficiency
Hypogammaglobulinemia
IgG Subclass Deficiency is Unclear
HIV Patients ( 30-68%)

36. Fungal Sinusitis Mycetoma Fungal Sinusitis
“Fungus Ball” Usually in the Maxillary Sinus
Treatment is Surgical Removal of the Lining
Allergic Fungal Sinusitis
An Allergic Reaction to Environmental Fungi
Immunocompetent Host
Thick Fungi and Mucin Accumulate
Surgical Removal of the Allergen(Fungi)

37. Fungal Sinusitis Chronic Indolent Sinusitis
Generally outside the U.S. (Sudan, India)
No Immune Deficiency
Progresses from Month to Years
Characterized by a Granulomatous Inflammatory Infiltrate

38. Fulminant Fungal Sinusitis
Immunocompromised Patients
Immunodefeciency Disorders (Diabetes)
Immunosuppressive Agents
Can Result in Progressive Destruction of the Sinuses with Resulting Invasion of the Eye or Cranial Cavity
Mucormycosis a common fungi

39. Sinus Headache
Clinical History: Primary Complaint is Headache Without Significant Nasal Symptoms – Migraine Headache Embedded In Other Bothersome Nasal Symptoms Evaluation of Nasal and Sinus Cavities Warranted Headache is a Minimal or Inconspicuous Complaint Rhinosinustis May Be Likely

40. Sinus Headache Physical Exam:
Nasal Exam Findings Which May Suggest Secondary Pathology:
Inflammatory Changes (Allergy)
Anatomic Abnormalities
Purulent Nasal Discharge
Testing:
Imaging Can Be Useful – False Positive Results

41. Sinus Headaches
Sinus Disease As A Cause of Headache Has Been Ingrained Into The American Public
Little Evidence to Support This
Migraine Can Present With Facial Pain, Nasal Congestion and Rhinorrhea.
In Clinical Studies Nearly 90% With Self-Diagnosed or Physician Diagnosed Sinus Headache Met The Criteria for IHS Migraine-Type Headaches.
Most Responded To Triptan Interventions

42. Sinus Headaches

43. Specialist Referral

44. Treatment
90% of Patients Can Be Treated and Cured of Sinusitis With Medical Therapy
Surgical Treatment:
For the Treatment of Anatomic Obstruction
(Polyps,Septal Deviations)
Recurrent Acute Infections
CRS Non-Responsive To Medial Therapy

45. Surgical Treatment Functions Endoscopic Sinus Surgery (FESS):
All done through the nose
Removal of Abnormal and Obstructive Tissue To Restore the Normal Drainage Pathways of the Sinuses
Results in Removal of Less Normal Tissue
Can Be Done as an Outpatient

46. Surgical Treatment Image Guided Surgery
Three Dimensional View of the Surgical Field For Severe Cases or Patients Who Have Had Prior Surgery Requires a Planning CT

47. BALLOON SINUPLASTY

48. Questions?