Sinusitis: Update on Management

Educational Objectives

The goal of this lecture is to improve the management of sinusitis and liver function abnormalities. After hearing and assimilating this lecture, the clinician will be better able to:

1. Distinguish acute sinusitis from chronic sinusitis.

2. List common causes of sinusitis.

3. Select appropriate treatment of rhinitis and sinusitis.

Summary

Introduction: rhinosinusitis — rhinitis (inflammation of nose) accompanied by sinus inflammation; sinusitis — inflammatory response involving mucus membranes of nasal cavities and perinasal sinuses; fluid within cavities; may involve underlying bone; chronic sinusitis — prevalence in United States 2% to 16%; socioeconomic impact significant

Classification of sinusitis: acute — <4 wk; chronic — >12 wk; subacute — 4 to 12 wk; symptoms improve with treatment

Acute Sinusitis

Acute rhinosinusitis: caused by rhinovirus, influenza virus, and parainfluenza virus; in adults, up to 2% of cases bacterial; in children, 6% to 8% of cases bacterial; after exposure to virus, symptoms develop ≤24 hr

Community-acquired acute bacterial rhinosinusitis: can be complication of acute viral sinusitis; causes — environmental allergies; mechanical obstruction of nose; polyps; swimming; tooth infection; immune deficiencies; cystic fibrosis; Corynebacterium; Staphylococcus aureus; in adults, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; in children, mostly due to H influenzae; nosocomial sinus infections occur in patients with long-term stay in intensive care unit or burn unit, or with long-term intubation, and patients develop Pseudomonas infection as well

Acute invasive fungal rhinosinusitis: occurs in immunodeficient patients with uncontrolled diabetes

Diagnosis of acute sinusitis: proposed criteria — presence of ≥2 major symptoms, or ≥1 major and ≥2 minor symptoms; major symptoms — purulent nasal discharge; nasal congestion; obstruction; facial congestion or fullness; hyposmia; anosmia; fever; minor symptoms — headache; ear pain; pressure or fullness; halitosis; dental pain; fever; fatigue

Differential diagnosis: includes common cold, facial pain, noninfectious rhinitis, headache, migraine, and dental pain

Clinical signs of bacterial sinusitis: 1) symptoms last >10 days with no improvement; 2) onset of severe symptoms (eg, fever >102°F) lasting ≥3 consecutive days at beginning of illness; 3) worsening symptoms following viral upper respiratory infection that lasted 5 to 6 days and was initially improving

Treatment: supportive therapy (treatment of symptoms); analgesics (eg, acetaminophen [eg, Acephen, Dapacin, Tylenol]); saline irrigation; some studies showed improvement of acute sinusitis with topical steroids; topical steroids effective for chronic sinusitis in combination with antibiotics; topical decongestants not recommended for long-term use; antihistamines can increase discomfort because of increased dryness; no evidence that mucolytic agents have role in acute or chronic sinusitis

Antibiotics for suspected bacterial infection: adults — amoxicillin; amoxicillin plus clavulanate (Augmentin); doxycycline for patients allergic to penicillin; macrolides, trimethoprim-sulfamethoxazole (eg, Bactrim, Cotrim, Septra), and cephalosporins not recommended; children — amoxicillin plus clavulanate drug of choice; cephalosporins (eg, cefdinir, cefpodoxime)

Chronic Sinusitis

Classification: with nasal polyps — 20% to 33% of cases; occurs mostly in adults; presence of allergic mucin in sinuses and significant eosinophil infiltration; Samter triad (≈15% of patients have aspirin sensitivity and asthma); 40% to 50% have asthma; most patients immunocompetent; without nasal polyps — ≈65% of cases; some eosinophil infiltration, but mononuclear cells and neutrophils predominant in sinuses; aspirin-associated respiratory disease rare; patients may or may not have immunoglobulin-mediated allergy to fungi; allergic fungal sinusitis — 8% to 12% of cases (uncommon); eosinophilic mucin with viable fungal hyphae seen on culture; skin testing positive for ≥1 molds; patients may be sensitive to aspirin and may have nasal polyps

Asthma: 40% to 50% of patients develop asthma after diagnosis of chronic sinusitis; chronic rhinosinusitis with nasal polyps and asthma present in 20% to 50% of patients (aspirin intolerance present in ≈15%); changes in asthma and later stages of chronic sinusitis — damage to epithelium; eosinophilic infiltration; thickening of basement membrane

Symptoms: primary — persist >12 wk; persistent nasal obstruction; purulent nasal drainage; facial pain, pressure, or fullness; decreased sense of smell; other — cough, sore throat, fever, and malaise

Microbiology: same as in acute sinusitis; Streptococcus; Haemophilus; M catarrhalis; anaerobes and S aureus isolated in most cases

Hypotheses of etiology and pathophysiology: bacteria — resistant to antibiotics; staphylococcal enterotoxins A and B trigger production of immunoglobulin E (IgE) and stimulate cytokines (eg, interleukin [IL]-5, IL-13) and other inflammatory cells; fungi — may trigger inflammatory response and persistent inflammation; 2004 study found that patients with chronic sinusitis and high concentration of inflammatory cytokines produced more immunoglobulin G (IgG) and IgE against molds; concluded that nasal mucosa colonized with different molds, however, in certain individuals, dysregulation or different immune response to these molds leads to chronic inflammation and sinusitis; eosinophils — primary trigger of inflammatory response in patients with chronic sinusitis with nasal polyps; influx of eosinophils independent of atopic status; some patients have peripheral eosinophilia

Predisposing factors: local — acute viral illness can lead to secondary infection; allergic rhinitis can cause nasal inflammation; concha bullosa (presence of hair cells in meatus can cause obstruction); adenoid hypertrophy in children; exposure to secondhand smoke; dental infection; foreign bodies; immune deficiency; systemic — cystic fibrosis; immotile cilia syndrome (rare); Wegener granulomatosis; Churg-Strauss vasculitis; patients with chronic sinusitis and nasal polyps usually not atopic

Symptoms in rhinitis and sinusitis: nasal congestion; cough; rhinorrhea; in rhinitis, nasal discharge predominantly clear (in sinusitis, discharge purulent); facial pain; hyposmia; throat clearing; fever not present in rhinitis

Treatment: combination of steroids and antibiotics — 2011 study looked at efficacy and tolerability of systemic methylprednisolone in children and adults with clinically and radiologically proven chronic rhinosinusitis; saw improvement in cough score, computed tomography (CT) score, postnasal drip, and total symptom score in patients treated with methylprednisolone and amoxicillin plus clavulanate, compared to those who received amoxicillin plus clavulanate and placebo; concluded that oral methylprednisolone provided added benefit to antibiotics in children with chronic rhinosinusitis; long-term treatment with oral corticosteroids associated with risk for side effects; nasal instillation of budesonide (eg, Pulmicort FlexHaler, Pulmicort Turbuhaler, Rhinocort Aqua) in patients with chronic sinusitis and nasal polyps — pilot study saw improvement in sinus score and CT score after treatment; other study of 60 patients with eosinophilic chronic rhinosinusitis with nasal polyps showed that transnasal nebulization with budesonide improved polyp size, nasal congestion, rhinorrhea, headache, loss of smell, and total nasal symptom score; inflammatory mediators (eg, eotaxin, IL-5) improved; no statistically significant improvement in IL-17 or interferon-γ; transnasal nebulization with budesonide safe and well tolerated; tissue structure improved with treatment; macrolide therapy — in 2014, meta-analysis concluded that long-term low-dose macrolide therapies ineffective for treatment of chronic rhinosinusitis; antifungal treatment — eg, intranasal treatment, nasal irrigation; amphotericin B not effective for chronic rhinosinusitis

Recommendations: antibiotics for at least 3 to 4 wk for chronic sinusitis; intranasal steroids and nasal irrigation for 10 to 14 days; antibiotics — amoxicillin plus clavulanate first-line treatment; clindamycin for penicillin-allergic patients; moxifloxacin; cefuroxime; levofloxacin; anaerobic coverage

Maintenance therapy: continue nasal irrigation and intranasal steroid; nasal instillation of budesonide (off-label use); consider aspirin desensitization in patients with nasal polyps and patients with aspirin-exacerbated respiratory disease, asthma, and chronic sinusitis

Readings

Ghaderi M: How closely related are allergic rhinitis, asthma, and chronic sinusitis? Ear Nose Throat J. 2013 Sep;92(9):410-2; Novis SJ et al: A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists. Int Forum Allergy Rhinol. 2016 Jan 11 [Epub ahead of print]; Pynnonen MA et al: Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort. Laryngoscope. 2015 Oct;125(10):2266-72; Rosenfeld RM et al: Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-S39; Rudmik L, Soler ZM: Medical Therapies for Adult Chronic Sinusitis: A Systematic Review. JAMA. 2015 Sep 1;314(9):926-39; Shaikh N, Wald ER: Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2014 Oct 27;10:CD007909; Wang T et al: The effectiveness topical amphotericin B in the management of chronic rhinosinusitis: a meta-analysis. Eur Arch Otorhinolaryngol. 2015 Aug;272(8):1923-9.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Pasha presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Pasha was recorded in Saratoga Springs, NY, on July 23, 2015, at the 21st Annual Asthma, Allergy and Immunology Update, presented by Albany Medical College. For information about upcoming events from this sponsor, visit www.amc.edu/Academic/CME/. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP641201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.