Lecture 8b - sinusitis

what are the 4 pairs of paranasal sinuses?

1-Frontal

2-Ethmoidal cells

3-Sphenoidal

4-Maxillary

Most common predisposing factor for acute rhinosinusitis is

viral upper respiratory tract infection

predisposing factors to developing sinusitis

- respiratory infections

- allergic rhinitis

- CF

- immunodeficiency

- irritants: tobacco smoke, pollution, chlorine

- overdue of intranasal decongestants

- cocaine abuse

- dental procedures

- diving

what are some sx associated with sinusitis

- Fever

- Nasal congestion

- Maxillary toothache

- Facial pain & swelling

- Headache

- Cough in children

what sx should not be used to diagnosis sinusitis and why?

colour of nasal discharge -- related to presence of neutrophils

what criteria is used to determine the diagnosis of acute sinusitis ...

@ least 2 symptoms of PODS w/ 1 being O or D:

P - facial Pain, pressure/fullness

O - nasal obstruction

D - nasal purulence/discolored discharge

S - smell distortion

what is considered the gold standard test in diagnosis acute sinusitis but is typically not done unless failure of treatment occurs?

puncture aspirate of sinus fluid

what pathogens tend to be involved in acute bacterial sinusitis (4 - 2 major ones)

1.S. pneumoniae

2. H. influenzae

sometimes:

3. M. catarrhalis

4. Mixed anaerobes

how to differentiated b/w bacterial & viral Rhinosinusitis

1. persistent sx lasting > 10 days with no improvement

2. severe sx or high fever (>39˙C) & purulent discharge or facial pain lasting 3-4 days at start of illness

3. worsening sx or new onset of sx following a viral URTI lasting 5-6 days that was initially improving (double sickening)

indicate most likely bacterial rather than viral

management options for acute sinusitis

- analgesics

- saline irrigation

- steam inhalation

- intranasal decongestants (< 5 days)

- 2nd gen antihistamines IF allergic component

- intranasal CS

- selective antibiotic therapy

what is the 1st line antibiotic treatment for sinusitis

amoxicillin

in an adult who either is immune compromised or has severe sx with no B-lactam allergy what is the first line antibiotic option & dose for sinusitis?

i.e has fever > 39 ˙C & purulent nasal discharge or facial pain for 3-4 days:

amoxicillin 1000mg BID +. amox/Clav 875 mg BID x 5-7 days

in a healthy adult with no B-lactam allergy what is the first line antibiotic option & dose for sinusitis?

amoxicillin 500mg TID x 5-7 days

1000mg if recent antibiotic use in last 3 months

in a healthy adult WITH a B-lactam allergy what is the first line antibiotic option & dose for sinusitis?

doxycycline 200mg once then 100mg BID x 5-7 days

in an adult who either is immune compromised or has severe sx WITH a B-lactam allergy what is the first line antibiotic option & dose for sinusitis?

hint: non-severe vs anaphylaxis

non-severe:

Ceftriaxone 1-2 g IV daily x 5 - 7 days

anaphylaxis:

Levofloxacin 750mg po daily x 5 days

in a healthy adult with no B-lactam allergy that received 1st line therapy for sinusitis but failed what is the next step up option?

Amoxicillin-Clavulanic Acid 875 mg BID x5-10 days

±

Amoxicillin* 1 gm po bid x 5 - 10 days

in an adult WITH a B-lactam allergy that received 1st line therapy for sinusitis but failed what is the next step up option?

Levofloxacin 750 mg po daily x 5 - 10 days

in a child with no B-lactam allergy and is NOT < 2 years, no recent antibiotic use or doesn't attend daycare what is the first line antibiotic option & dose for sinusitis?

Amoxicillin 40 mg/kg/day div tid x 10 days

in a child with no B-lactam allergy and HAS one of the following criteria: < 2 years, recent antibiotic use or. attends daycare what is the first line antibiotic option & dose for sinusitis?

Amoxicillin 90 mg/kg/day div bid-tid x 10 days

in a child with no B-lactam allergy but has severe sx or is immunocompromised what is the first line antibiotic option & dose for sinusitis?

Amoxicillin 45 mg/kg/day

+

Amox/Clav 7:1 45 mg/kg /day

each div bid-tid x 10 days

in a child WITH a penicillin allergy what is the first line antibiotic option & dose for sinusitis?

Clindamycin 20-30 mg/kg/d div tid + Cefixime 8 mg/kg/d div bidx 10 days

OR

Cefuroxime 30mg/kg/d po div bid x10 days

in a child WITH a penicillin allergy and either severe sx or is immunocompromised what is the first line antibiotic option & dose for sinusitis?

a) non-severe allergy

b) severe allergy

Non- Severe Allergy : Ceftriaxone 100 mg/kg/day IV daily

Severe Allergy

(*Doxycycline 4mg/kg/d div bid) (> 8 yrs old)

(*TMP/SMX 8-12 mg/kg/d TMP div bid)

Levofloxacin 10-20 mg/kg IV/PO div q12-24h

in a child with no B-lactam allergy but has had failure with the 1st line therapy option what is the the next step up option & dose for sinusitis?

Amox/Clav 7:1 45 mg/kg /day ± Amoxicillin* 45 mg/kg/day

each div bid-tid x 10 days

if had high dose amoxicillin then anox/clav is adequate alone

in a child with a penicillin allergy but has had failure with the 1st line therapy option what is the the next step up option & dose for sinusitis?

Clindamycin 20-30 mg/kg/d div tid + Cefixime 8 mg/kg/d div bidx 10 days

in a child with a penicillin allergy & has severe sx or is immunocompromised but has had failure with the 1st line therapy option what is the the next step up option & dose for sinusitis?

Ceftriaxone 100 mg/kg/day IV daily

OR

Levofloxacin 10-20 mg/kg div q12-24h (severe allergy)