1. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. Terms of Use  The In the Clinic ® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for- profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.

2. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

3. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. in the clinic Acute Sinusitis

4. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What factors increase the risk for acute sinusitis? Most common: Recent viral URI or allergies  Asthma (Triad: asthma, nasal polyps, ASA intolerance)  Age (old:  immunity,  URI, dry/weak nasal cartilage)  Environmental irritants (smoke, chlorine)  Atmospheric pressure changes (air travel)  Dental/periodontal infection or sinus perforation during tooth extraction  Kartagener syndrome (sinusitis, bronchiectasis, dextrocardia)

5. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What factors increase the risk for acute sinusitis? Most common: Recent viral URI or allergies  Immune deficiency (AIDS, poorly controlled diabetes)  risk fungal invasive sinusitis  Cystic fibrosis  Autoimmune disease (Wegener granulomatosis)  Hospitalization (Abx or steroid Rxs, NG or ET tubes)  Pregnancy  Facial injury or structural abnormality  deviated septum, nasal polyp

6. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. How can patients decrease their risk for acute sinusitis?  Frequent hand-washing  Avoid sick contacts  Avoid allergens, irritants (smoke, chemicals, strong odors)  Nasal corticosteroids, immunotherapy (prevent recurrent sinusitis in allergic persons)  Decongestant nose drops (before air travel)  Humidifier, steam inhalation, nasal irrigation

7. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1.

8. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of the history and physical exam in the diagnosis of acute sinusitis? H&P  Basis for diagnosis  No accepted office-based test  Gold-standard: culture aspirate from antral puncture (Not routine  painful, risks, requires expertise)

9. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of the history and physical exam in the diagnosis of acute sinusitis? Other Signs & Symptoms  Nasal congestion or obstructuction  Postnasal drainage  Hyposmia or anosmia  Ear pressure  Cough  Worsening symptoms after initial improvement Check for:  Swollen turbinates  Purulent rhinorrhea  Nasal polyps  Sinus pain if bending over  Oropharyngeal red streak Primary Symptoms: Purulent rhinitis & facial pain (esp combo) Ask about:  Allergies & other risk factors  Symptom duration (<10 days  unlikely bacterial)

10. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. Why is it important to distinguish acute sinusitis from chronic sinusitis? Acute  Cause: usually viral URI  Duration: 1 - <4 wks  Typically more severe  Chronic sinusitis Poor response to usual Abx Rx Longer Rx often needed Surgery if refractory to medical Rx Acute exacerbations  Poorer response: severe allergies, structural changes from chronic sinusitis itself or prior surgery) Chronic  Cause: inflammation & blockage (allergies, septal deviation, polyps, tumors, foreign body)  Duration: t >4 wks- years

11. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What noninfectious conditions should clinicians consider when evaluating for acute sinusitis?  Allergic rhinitis  Drug-induced rhinitis (decongestant use >5 d, cocaine)  Recurrent viral URIs  Dental pain Chronic sinusitis if symptom duration > 12 wks  distinct differential dx  Occupational rhinosinusitis  Gastroesophageal reflux  Migraine/tension headache  Nasal polyps (obstruction)

12. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of imaging in the diagnosis of acute sinusitis?  Imaging not routinely required or appropriate  Xray evidence “sinusitis” in 87% viral URIs  But <3% progress to bacterial infection  Not cost-effective c/w symptomatic Rx or criteria-guided Abx

13. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of imaging in the diagnosis of acute sinusitis? Consider Xray :  Sxs ≥ 7-10 d + Non-response/recur w/Rx  Other conditions seriously considered  Risk of complications (e.g., immunocompromised)  Possible atypical microbe (e.g., Pseudomonas aeruginosa, or fungal infection w/ immunocompromise) Consider CT/MRI :  Possible local spread or intracranial complications  Symptoms persist >3 wks despite Rx or recur Occipitomental view (Waters):  Standard for paranasal sinuses, esp maxillary  3 or 4 often ordered Positive radiographs:  Sinus fluid/opacity  Mucous membrane thickening >50%

14. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of laboratory testing in the diagnosis of acute sinusitis?  Usually NOT needed  If Rx non-response or worsening symptom: culture Gold standard: Sinus puncture (maxillary)  Invasive, risk of pain, bleeding, swelling, false passage Alternative: Transnasal endoscopic culture  Requires ENT: topical anesthetic, less invasive Nasal swab / culture (direct swab thru nose)  Poor correlation w/sinus pathogens  Contamination w/normal nasal flora

15. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What is the role of laboratory testing in the diagnosis of acute sinusitis?  Other lab tests: depend on clinical situation  CBC w/with differential  TFT for fatigue  Chloride testing for CF  If sinusitis recurrent/persistent  refer for evaluation of allergy/immune deficiency

16. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What organisms can cause acute sinusitis? ~⅓ H. influenzae & most M. catarrhalis resistant to penicillin/amoxicillin  Production β-lactamase (H. influenzae, M. catarrhalis, Staphylococcus aureus, Fusobacterium spp., and Prevotella spp.) or Changes in penicillin-binding protein (S. pneumoniae) Pts w/ more resistant bacteria often need antimicrobial Tx directed at all pathogens in mixed infections Predominant isolates (>50% acute bacterial sinusitis) Streptococcus pneumonia Haemophilus influenzae Other bacteria: Moraxella catarrhalis (esp children & young adults) and Streptococcus pyogenes Acute fungal sinusitis (less common) Aspergillus Mucor Usually occur in immunocompromised Fulminant invasive disease  high mortality if not treated early, aggressively (nasal surgery)

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18. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What nondrug measures are helpful in the treatment of patients with acute sinusitis?  Steam inhalation  Hydration  Sinus irrigation (e.g, neti pot) How to Perform Nasal Irrigation  Salt-water solution: 1/2 tsp noniodinated salt 1/2 tsp baking soda 8-oz warm water  Place in delivery device (e.g., neti pot, bulb syringe)  Lean over sink, head down, chin up  Pour/squeeze water gently in upper nostril (drains out other nostril)  Repeat on other side  Increase mucosal moisture, thin mucus, aid sinus drainage  Remove inflammatory debris & bacteria

19. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. How should clinicians decide whether to use antibiotics to treat acute sinusitis? Probability of Bacterial Sinusitis  ≥ 2: high probability (>50%)  < 1: low probability (<25%)  URI >7 days  facial pain  purulent discharge (nasal, pharyngeal, or both)  Antibiotic therapy appropriate if:  High probability bacterial sinusitis  Symptomatic Rx fails in low-probability patients

20. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. How should clinicians decide whether to use antibiotics to treat acute sinusitis?  Choice of Abx determined by circumstances  Increased pneumococcal resistance to macrolides  Trimethoprim–sulfamethoxazole acceptable 1 st -line agent in adults, but not recommended in children  Broad-spectrum agents usually not necessary for 1 st -line Rx  Cephalosporins  Fluoroquinolones  More costly  Concern promoting resistance among bacteria in community & host

21. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. How should clinicians decide whether to use antibiotics to treat acute sinusitis?  Amoxicillin  1 st line agent  If no improvement after 3-5 d, consider alternative Abx  AEs: rash, GI symptoms, hypersensitivity reaction (rare)  Use if penicillin allergy or persistent symptoms  Broader spectrum than amoxicillin  Covers β-lactamase–producing strains H. influenzae, M. catarrhalis  AEs: GI upset, neutropenia, photosensitivity, not rec’d in children ≤8 y  Use if: Penicillin allergy or persistent symptoms Pneumococcal resistance ≥24%  Not for children  No improvement after 3-5 d, consider alternative antibiotic  AEs: rash, GI symptoms, hematologic (rare), toxic epidermal necrolysis (rare)  2 nd -generation (cefpodoxime) for 2 nd -line use (1 st - generation minimal efficacy against S. pneumoniae, H. influenzae)  Caution if penicillin allergy  AEs: GI upset, headache, rash, blood dyscrasias  Doxycycline  Trimethoprim–sulfamethoxazole  Cephalosporins

22. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. How should clinicians decide whether to use other drugs to treat acute sinusitis? Nasal steriods (fluticasone)  Reduces mucosal inflammation  May cause local irritation Oral corticosteroids  For severe disease, reduces pain Oral antihistamines (loratadine)  Anti-inflammatory, helpful with allergic rhinitis Nasal decongestant (xylometazoline)  Anti-inflammatory, vasoconstriction- improves ostial drainage  Avoid use for ≥3-5 d  risk for rebound congestion Systemic decongestants (pseudoephedrine)  Caution if CVD, poorly controlled hypertension, hyperthyroidism, diabetes mellitus Mucolytic agents (guaifenesin)  Reduces viscosity of nasal secretions  May cause GI symptoms  Initial therapy in pts w/ low probability bacterial disease  Relieve symptoms  Restore normal sinus environment and function  Efficacy varies, evidence limited

23. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What are complications of acute sinusitis?  Serious complications rare when managed properly  Proximity of sinuses to CNS  infection can become life threatening if spreads: may require CT for Dx  Intracranial: Extension into ostial/meningeal structures (abscess)  Orbital/Periorbital cellulitis: Orbital extension (inflammation, abscess, blindness)  Aneurysm/blood clot: Extension from sphenoid sinus to carotid artery or cavernous sinus (may be fatal)  Nerve injury: Permanent loss of smell or taste

24. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. What are complications of acute sinusitis? Clinical alerts  Orbital swelling, conjunctival erythema, limited extraocular movements  Focal neurologic signs  Altered mental status  Abnormal culture on sinus puncture  Exacerbation of asthma

25. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. When should clinicians consult a specialist?  Complicated patients, severe symptoms, or nonresponsive to initial therapy  Otolaryngologist: When nonresponse to initial Rx or sinus recurrent/chronic infections, or if anatomical abnormality suspected  Allergist: Underlying atopic disease, recurrent sinus infections or symptoms persistent; treating sinus condition improves asthma  May require ophthalmologist, neurosurgeon, ID expert, or neurologist, depending on symptoms  Hospitalize with serious complications: orbital involvement, infection or thrombosis of the intracranial venous sinuses, or metastatic spread to CNS

26. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. Do special considerations exist for care of patients with recurrent acute sinusitis?  Reevaluate when  Symptoms persist wks  New or worsening symptoms  Failure to improve may indicate  Antibiotic resistance  Significant allergic inflammation  Fungal infection (rather than bacterial)  Presence of complications Can be difficult to determine: Does recurrence represent relapse or de novo episode?

27. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. Do special considerations exist for care of patients with recurrent acute sinusitis?  Check for: Persistent fever, sinus tenderness, purulent discharge, change in mental status/vision  Assess factors that could modify Rx: Allergic rhinitis, anatomical variation, CF, ciliary dyskinesia, immune compromise  Imaging studies & bacterial cultures: May guide Rx course & assess ? complications  If no anatomical anomalies upon evaluation: Try 2 nd -line antibiotic therapy

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29. © Copyright Annals of Internal Medicine, 2010 Ann Int Med. 152 (9): ITC5-1. Are there practice guidelines relevant to acute sinusitis?  Joint Council of Allergy, Asthma, and Immunology (2005): fungi  factor in chronic sinusitis  American College of Chest Physicians (2006): Make no dx in 1 st wk symptoms  American Academy of Otolaryngology—Head and Neck Surgery Foundation (2007): Consider other causes, complications when worse or no improvement 7 d after dx and mgmt  British National Institute for Health and Clinical Excellence (2008): Use “No antibiotic or delayed antibiotic strategy" for most  Agency for Healthcare Research and Quality (2005): Few studies compare efficacy newer antibiotics w/older, less expensive ones