Lecture 8a - Sinusitis

what are the 4 pairs of paranasal sinuses

frontal sinuses (over eyes)

maxillary sinuses (cheekbones)

ethmoid sinuses (behind nose)

sphenoid sinuses (behind eyes)

when do the paranasal sinuses develop

maxillary and ethmoid → present at infancy

sphenoid → present 3 yo, develop up to age 12

frontal → appear by 5 yo, develop into adolscence

what is the function of turbinates

warm and humidify air

what is an osteo

opening of a sinus cavity to the nose

each sinus has one

what is the most common predisposing factor for acute rhinosinusitis

viral upper respiratory tract infection

what is a rare cause of acute rhinosinusitis

rarely colds are complicated by acute bacterial sinusitis

what medical conditions are predisposing factors for sinusitis

respiratory infections

allergic rhinitis

cystic fibrosis

immunodeficiency

Wegener’s syndrome

what irritants are predisposing factors for sinusitis

tobacco smoke

pollution

chlorine

what anatomic factors are predisposing factors for sinusitis

deviated nasal septum

enlarged adenoids

immotile cilia

polyps

tumours

foreign bodies

what medications are predisposing factors for sinusitis

overuse of intranasal decongestants

cocaine abuse

what traumas are predisposing factors for sinusitis

dental procedures

diving

how can sinusitis be prevented

limit spread of viral infections by handwashing

avoid environmental tobacco smoke

avoid allergen exposure

regular influenza and other vaccinations

what are minor sx of sinusitis

fever

nasal congestion

maxillary toothache

facial pain/swelling

headache

cough - children

should the colour of nasal discharge be used to diagnose sinusitis

NO

colour = related to presence of neutrophils → should NOT be used to dx sinusitis

what are the major symptoms of sinusitis (acronym)

P - facial pain, pressure/fullness

O* - nasal obstruction

D* - nasal purulence/discoloured postnasal discharge

S - hyposmia/anosmia (smell)

what is the diagnostic criteria for sinusitis

requires at least 2 PODS symptoms

at least one symptoms must be nasal obstruction or nasal purulence/discoloured postnasal discharge (O or D)

possible to have 1 PODS symptom and 2 minor criteria for diagnosis

what is the gold standard for diagnosis of acute sinusitis

puncture aspirate of sinus fluid

not usually done unless failure of treatment

what pathogens are commonly associated with acute bacterial sinusitis

S pneumoniae

H influenzae

M catarrhalis

mixed anaerobes

rarely S aureus, S pyogenes, aerobic gram negative organisms

20% have respiratory viruses alone or with bacterial pathogens

what is the difference between bacterial and viral rhinosinusitis

bacterial symptoms:

sx lasting ≥ 10 days without improvement

high fever (≥39) and purulent discharge/facial pain, lasting at least 3-4 days at the beginning of illness

worsening symptoms or new symptoms e.g. fever, headache, increase in discharge following viral URTI that lasted 5-6 days and was initially improving (double sickening)

what options are available to manage acute sinusitis

analgesics

irrigation with normal saline, inhalation of steam

intranasal decongestants < 5 days

2nd gen antihistamines may be recommended if allergic component

nasal corticosteroids - may benefit in recurrent and/or allergic rhinosinusitis

selective antibacterial therapy

what is a reasonable first choice for acute sinusitis

amoxicillin

what is the recommended dose of amoxicillin for adults for initial therapy

amoxicillin 500mg - 1g tid x 5-7 days

(use 1g if abx in last 3 months)

shorter course of therapy recommended

what is the recommended dose for initial therapy for amoxicillin for severe cases/immunocompromised

(fever > 39 and purulent nasal discharge/facial pain 3-4 days)

amoxicillin 1g bid PLUS amox/clav 875mg bid x 5-7 days

what antibacterials are recommended as initial therapy for adults with beta lactam allergy

doxycycline x 5-7 days

what antibacterials are recommended as initial therapy for adults with beta lactam allergy for severe illness/immunocompromised

non-severe allergy → ceftriaxone x 5-7 days

severe allergy/anaphylaxis → levofloxacin x 5 days

what is the recommended dose of amoxicillin for adults who failed initial treatment with amoxicillin or amoxicillin + amoxi/clav

amoxicillin-clavulanic acid 875mg po bid x 5-10 days

± amoxicillin 1g po bid x 5-10 days

(if patient failed high dose amoxicillin only, amoxi/clav is adequate)

what is the recommended antibacterial for adults who failed initial treatment and are beta lactam allergic

levofloxacin x 5-10 days

what should you do if infection comes back within 3 months

consider allergy testing

topical intranasal corticosteroids may be of benefit → use early before closure of ostea

recommend referral to ENT if ≥ 4 epidoses per year

what is initial treatment for pediatric patients > 2 years, no recent ABX, no daycare attendance

amoxicillin 40 mg/kg/day divided tid x 10 days

what is initial treatment for pediatric patients with any of the following:

< 2 years, recent ABX, daycare attendance

amoxicillin 90 mg/kg/day divided bid-tid x 10 days

what is initial treatment for pediatric patients if severe infection or immunocompromised

amoxicillin 45 mg/kg/day PLUS amoxi/clav 7:1 45 mg/kg/day

each divided bid-tid x 10 days

what is initial treatment for pediatric patients with non-severe penicillin allergy

clindamycin + cefixime x 10 days

or cefuroxime x 10 days

what is initial treatment for pediatric patients with non-severe penicillin allergy in cases of severe infection of immunocompromised

ceftriaxone

what is initial treatment for pediatric patients with severe penicillin allergy in cases of severe infection of immunocompromised

doxycycline

or trimethoprim/sulfamethoxazole

or levofloxacin

what is recommended treatment for pediatric patients who failed initial treatment with amoxicillin

amoxi/clav 7:1 45 mg/kg/day PLUS amoxicillin 45 mg/kg/day

each divided bid-tid x 10 days

(if patient failed initial high dose amoxicillin, amoxi/clav alone is adequate)

what is recommended treatment for pediatric patients who failed initial treatment with non-severe penicillin allergy

clindamycin + cefixime x 10 days

what is recommended treatment for pediatric patients with non-severe penicillin allergy who failed initial treatment in cases of severe infection of immunocompromised

ceftriaxone

what is recommended treatment for pediatric patients with severe penicillin/ceph allergy who failed initial treatment in cases of severe infection of immunocompromised

levofloxacin