sinusitis and URI reading

ostiomeatal complex (OMC)

common drainage site for frontal, maxillary, anterior ethmoid sinuses.

-important pathway in sinusitis

Viral (most common): Rhinovirus, coronavirus, adenovirus, RSV, influenza.

most common causes of URI

group A strep

most common cause of bacterial URI

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

most common causes of acute bacterial rhinosinusitis

Viral:

differentiating viral vs bacterial sinusitis via history

frontal lift, maxillary lift, venous sinus drainage

cranial techniques for sinusitis

sinus effleurage

1. frontal sinuses

- start at frontal sinus with thumbs and move down to peri-auricular nodes, then down SCM over the superficial anterior chain

2. Maxillary sinuses

- start at maxillary → PA nodes → down over SCM and the SAC

3. Submental:

- start at the submental → up to PA nodes → down over SCM and the SAC

Transillumination of sinuses

absense of a glow on one or both sides suggest a thickened mucosa or secretions in the sinus, but it may also result from develpmentsal absence of one or both sinuses (frontal). See text for description of methods for transillumination of sinuses

postnasal drip, cobblestoning

oropharynx findings associated with sinusitis

Periorbital swelling, diplopia, altered mental status → possible complication.

red flags of sinusitis

Moraxella catarrhalis

cause of bacterial sinusitis especially in kids

Staphylococcus aureus, anaerobes (chronic cases)

less common causes of bacterial sinusitis

Mucor, Aspergillus

fungal causes of sinusitis

Deviated septum

Nasal polyps

Narrow sinus ostia

anatomic risk factors for sinusitis

Smoking, air pollution, occupational exposures

environmental risk factors for sinusitis

Overuse of topical α-adrenergic agonists (e.g., oxymetazoline, phenylephrine, xylometazoline) for >3-5 days

what causes rhinitis medicamentosa?

oxymetazoline, phenylephrine, xylometazoline

agents that can cause rhinitis medicamentosa

rhinitis medicamentosa

Initial vasoconstriction reduces congestion.

With chronic use, rebound vasodilation and mucosal edema occur.

Leads to rebound congestion, dependence, and worsening nasal obstruction

Discontinue spray (difficult, may need gradual wean)

Saline sprays, intranasal corticosteroids to reduce rebound swelling

management of rhinitis medicomentosa

Symptoms persist ≥10 days without improvement

Severe symptoms (fever ≥39°C/102°F, purulent nasal discharge, facial pain) for ≥3-4 consecutive days

Double-worsening: Patient improves initially, then worsens (suggests secondary bacterial infection)

Immunocompromised or high risk of complications

indications for antibiotics to treat sinusitis

Amoxicillin-clavulanate

first line treatment for acute bacterial sinusitis

Adults: 5-7 days

Children: 10-14 days

how long is a course of abx for bacterial sinusitis

doxycycline (adults only), levofloxacin/moxifloxacin

alt abx for sinusitis in PCN allergic

fluticasone, mometasone → reduce inflammation, esp. with allergic rhinitis

intranasal corticosteroids for sinusitis relief

pseudoephedrine, oxymetazoline → short-term only (≤3 days for sprays to avoid rhinitis medicamentosa)

nasal decongestants for sinusitis relief

sometimes add long-term low-dose macrolide or culture-guided antibiotics

treatment for chronic sinusitis

uncontrolled HTN, CAD, arrhythmias.

these decongestants (pseudophedrine, phenylephrine) are contraindicatd in pts with

Orbital cellulitis/abscess, cavernous sinus thrombosis, osteomyelitis of frontal bone

potential local complications of sinus infections

Meningitis, brain abscess, subdural empyema.

intracranial complications of sinus infections

Gallbreath technique (mandibular drainage)

Used to release the eustachian tube