Lecture
24 y/o with fever and right-sided sinus pain
Patient will present as → a 34-year-old previously healthy male with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a “common cold,” which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green-tinged rhinorrhea. His temperature is 100.1 F (37.8 C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. The nasal exam reveals edematous turbinates and purulent discharge. The patient has facial tenderness with palpation over the involved sinus.
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Looking for symptoms that worsen over 5-7 days or do not improve in > 10 days
- Symptoms: fever, facial pain, a headache that can radiate to the upper teeth, purulent rhinorrhea, congestion, and loss of smell
- Physical exam: Classically, facial tenderness with palpation over the involved sinus
Acute sinusitis
- < 4 weeks duration
- Sudden onset
- Most commonly caused by S. pneumoniae, H. influenzae, Moraxella catarrhalis
- Usually precipitated by an acute viral respiratory tract infection which is thought to lead to reduced clearance of mucus
Chronic sinusitis
- > 12 consecutive weeks
- Associated bacteria include S. aureus, anaerobes, and gram-negative organisms such as Pseudomonas aeruginosa
- Other risks include systemic disease, anatomic anomalies, trauma, noxious chemicals such as pollutants or smoke, and medications
The disease is subacute when symptomatic for 4–12 weeks and chronic when symptomatic for >12 weeks.
Plainview X-ray (Waters' view) has fallen out of favor due to poor sensitivity
- Sinus CT is the GOLD STANDARD
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Front view illustration and side-by-side CT scans of normal and chronic sinusitis
Diagnosis of acute bacterial rhinosinusitis (ARBS):
- ABRS should be diagnosed when signs and symptoms of acute rhinosinusitis (ARS) (purulent nasal drainage plus nasal obstruction, facial pain-pressure or both) persist without improvement for at least 10 days OR if signs and symptoms worsen within 10 days after initial improvement.
Diagnosis of chronic sinusitis:
- Chronic rhinosinusitis is characterized by 12 weeks or more of at least two of four cardinal symptoms: nasal obstruction, anterior or posterior nasal discharge, reduction or loss of smell, and facial pain/pressure/fullness.
- In addition, there must be objective evidence of mucosal inflammation, either by direct visualization or on an imaging study (usually sinus computed tomography [CT] scan)
Indications for antibiotics in rhinosinusitis include
- Duration of symptoms >10 days without improvement
- Fever greater than 102 F and/or purulent nasal discharge
- Rapid worsening of symptoms after initial improvement
First-line therapies for bacterial sinusitis in adults include (treat for 5–7 days in adults)
- Amoxicillin 500 mg orally three times daily or 875 mg orally twice daily (for patients without risk factors for pneumococcal resistance )
- Amoxicillin-clavulanate (Augmentin) 500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily
Penicillin allergic
- Doxycycline 100 mg orally twice daily or 200 mg orally daily
- Cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) prescribed with or without clindamycin (300 mg every six hours)
Second-line therapy (for those who fail to improve within 7 days) includes high-dose Augmentin (2 g BID x 7 days), Moxifloxacin, Levofloxacin, or a third-generation cephalosporin plus clindamycin. If improvement is seen within 7 days of initiation of therapy, antibiotic treatment should be continued for a total course of 7 to 10 days.
- Amoxicillin-clavulanate 2 g/125 mg extended-release tablets orally twice daily
- Levofloxacin 500 or 750 mg orally once daily
- Moxifloxacin 400 mg orally once daily
For penicillin-allergic patients, options include:
- Doxycycline 100 mg orally twice daily or 200 mg orally daily
- Levofloxacin 500 or 750 mg orally once daily
- Moxifloxacin 400 mg orally once daily
Chronic rhinosinusitis (CRS) lasts 12 weeks or longer despite attempts at medical management. Therapy is typically given for at least three weeks and may be extended for up to ten weeks in refractory cases
- Amoxicillin-clavulanate: 875 mg twice daily or two 1000 mg extended-release tablets twice daily
- Pen allergic: Clindamycin 300 mg four times daily or 450 mg three times daily
Children first-line is Amoxicillin-clavulanate 45 mg/kg per day in 2 divided doses if uncomplicated acute bacterial sinusitis
- Treat for 10–14 days in children if uncomplicated bacterial rhinosinusitis
- Third-generation cephalosporin (e.g., cefpodoxime or cefdinir) in children with penicillin allergy
- If there is no improvement after 72 hours, switch to a second-line agent
 Osmosis |
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Picmonic
Rhinosinusitis and treatments
Rhinosinusitis is the inflammation of the sinuses. It’s usually preceded by an upper respiratory infection. Diagnosis is usually based on symptoms including nasal drainage, facial pain, retroorbital pain, or a fever if worsening.
| Rhinosinusitis assessment | Play Video + Quiz |
| Beta lactamase inhibitors | Play Video + Quiz |
| Cephalosporins | Play Video + Quiz |
Question 1 |
Acute bacterial rhinosinusitis (ABRS) can be distinguished from acute rhinosinusitis due to viral respiratory infections and noninfectious conditions by which of the following criteria?
Duration and time course of compatible symptoms | |
Presence of purulent nasal discharge Hint: While purulent discharge can be present in ABRS, it's also seen in viral infections and isn't reliable for distinguishing the two. | |
Response to nasal decongestants Hint: Symptom improvement with decongestants can occur in both viral and bacterial sinusitis. It doesn't help differentiate between the two. | |
Severity of facial pain and fever Hint: Both ABRS and AVRS can cause these symptoms, though sometimes higher temperatures are seen in bacterial infections. However, there's significant overlap. | |
Sinus tenderness on physical examination Hint: This is found in both ABRS and AVRS and lacks specificity. |
Question 1 Explanation:
ABRS should be diagnosed when signs and symptoms of acute rhinosinusitis (ARS) (purulent nasal drainage plus nasal obstruction, facial pain-pressure or both) persist without improvement for at least 10 days or if signs and symptoms worsen within 10 days after initial improvement.
Question 2 |
A 35-year-old man presents with chronic nasal congestion, thick nasal discharge, facial pressure, and occasional headaches for the past 3 months. Symptoms improve minimally with over-the-counter decongestants and antihistamines. Which of the following is the most appropriate next step in this patient's diagnostic evaluation?
Transillumination of sinuses Hint: Transillumination is used in the initial evaluation of chronic or acute sinusitis, but is not sensitive or specific. | |
Sinus X-ray Hint: Less sensitive than CT for soft tissue visualization (polyps, etc.) and doesn't provide the same detailed sinus anatomy view. | |
CT scan of sinuses | |
Nasal culture Hint: Nasal culture is not indicated in the evaluation of chronic sinus infections. | |
Allergy skin testing Hint: While allergies can predispose some to inflammation contributing to sinusitis, they aren't a primary initial assessment in suspected chronic sinusitis with this severity. |
Question 2 Explanation:
A CT scan offers the most comprehensive assessment of the sinus anatomy and potential inflammatory changes/obstructions contributing to chronic sinusitis. It aids in determining severity and helps determine appropriate treatment/potential referral to ENT.
Question 3 |
In adults, which of the following bacteria is the most frequent cause of acute bacterial sinusitis?
Streptococcus pneumoniae | |
Staphylococcus aureus Hint: While a potential cause of sinusitis, S. aureus is less common than S. pneumoniae in uncomplicated cases. It may be seen more frequently in chronic or complicated sinusitis. | |
Haemophilus influenzae Hint: H. influenzae is another significant cause of acute bacterial sinusitis, especially in children and those with underlying conditions. However, S. pneumoniae is still the most prevalent overall. | |
Pseudomonas aeruginosa Hint: P. aeruginosa is uncommon in community-acquired sinusitis. It's more frequently associated with hospital-acquired infections or immunocompromised patients. | |
Moraxella catarrhalis Hint: Similar to H. influenzae, M. catarrhalis contributes to acute bacterial sinusitis but is less common than S. pneumoniae as the primary agent. |
Question 3 Explanation:
The typical pathogens associated with acute bacterial sinusitis are Streptococcus pneumoniae, other streptococci species, and Haemophilus influenzae. Moraxella catarrhalis and Staphylococcus aureus are less common causes. Pseudomonas is a less common cause and would be associated with nosocomial infection often in a critically ill patient. Mycoplasma is not a typical cause of bacterial sinusitis.
Question 4 |
An otherwise healthy college student presents with complaints of cough, malaise, fever, sore throat, yellow-green nasal discharge, and headache for the past 3 weeks. She complains of facial pain over the cheeks and while chewing. On examination, the nasal turbinates are erythematous and edematous nearly obstructing the nares bilaterally. Her face is tender to palpation over the maxillary sinuses. She has not been previously evaluated. Which of the following is the next best step in the management of this patient?
Prescribe amoxicillin/clavulanate (Augmentin) | |
Prescribe azithromycin Hint: Both azithromycin and TMP-SMX are associated with high rates of bacterial resistance (because of overuse in patients with viral sinusitis ), and should only be used in patients who fail initial therapy or are allergic to penicillins. | |
Prescribe trimethoprim-sulfamethoxazole (TMP-SMX) Hint: Both azithromycin and TMP-SMX are associated with high rates of bacterial resistance (because of overuse in patients with viral sinusitis ), and should only be used in patients who fail initial therapy or are allergic to penicillins. | |
CT Head Hint: Imaging cannot differentiate viral from bacterial URI and generally does not change management in uncomplicated cases. It can be useful, though, in complicated cases or patients unresponsive to initial therapy. | |
Sinus aspiration Hint: Sinus aspiration is the gold standard for diagnosing a sinus infection as bacterial. However, it is invasive, time-consuming, painful for patients, and wholly unnecessary to diagnose and properly treat bacterial sinusitis. |
Question 4 Explanation:
Amoxicillin - clavulanate is the recommended first-line treating agent (for a 5-7 day course in uncomplicated cases) in treating bacterial rhinosinusitis. The diagnosis of acute bacterial sinusitis should be entertained under either of the following circumstances: presence of symptoms or signs of acute rhinosinusitis 10 days or more beyond the onset of upper respiratory symptoms, and worsening of symptoms or signs of acute rhinosinusitis within 10 days after an initial improvement. First-line therapy is amoxicillin with or without clavulanate.
Question 5 |
A 42-year-old woman presents with a 4-month history of nasal obstruction, thick nasal discharge, facial pressure, and a decreased sense of smell. She has tried over-the-counter antihistamines with no significant relief. A CT scan of the sinuses reveals mucosal thickening in the maxillary and ethmoid sinuses without the presence of nasal polyps. Which of the following is the most appropriate initial treatment for this patient?
Oral glucocorticoids Hint: While short courses of oral glucocorticoids may be considered for patients with persistent symptoms despite initial interventions, they are not recommended as the first-line treatment due to potential systemic side effects.
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Intranasal corticosteroids and high-volume saline irrigations | |
Extended course of macrolide antibiotics Hint: An extended course of macrolide antibiotics is considered for patients with persistent symptoms who have contraindications to surgery or recurrent symptoms following surgery, not as initial therapy. | |
Referral for functional endoscopic sinus surgery (FESS) Hint: FESS is suggested for patients with persistent symptoms despite nonsurgical interventions. It is not indicated as an initial treatment before attempting medical management. | |
Respiratory biologic therapy Hint: There are no approved biologic therapies for CRSsNP alone. Biologics may be considered in patients with coexistent conditions that can be treated with respiratory biologics, such as moderate-to-severe asthma, not as a first-line treatment for CRSsNP. |
Question 5 Explanation:
Chronic rhinosinusitis is characterized by 12 weeks or more of at least two of four cardinal symptoms: nasal obstruction, anterior or posterior nasal discharge, reduction or loss of smell, and facial pain/pressure/fullness. In addition, there must be objective evidence of mucosal inflammation, either by direct visualization or on an imaging study (usually sinus computed tomography [CT] scan). Intranasal corticosteroids and high-volume saline irrigations are recommended as initial therapy for patients with CRSsNP. This combination addresses the inflammation and helps clear the sinus passages, potentially improving symptoms such as nasal obstruction and thick nasal discharge. High-volume saline irrigations can help with mucosal clearance, while intranasal corticosteroids reduce inflammation. This approach is consistent with multiple guidelines and should be continued for at least two months as improvement may be gradual. For patients with persistent symptoms, there are several options for additional treatments but very few studies to define their relative efficacy. Usually this involves a short course of both oral glucocorticoids and antibiotics.
There are 5 questions to complete.
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References: Merck Manual · UpToDate