RHINOSINUSITIS

Stuart Henochowicz, M.D., M.B.A., F.A.C.P.

Clinical Associate Professor
Division of Allergy, Immunology and Rheumatology
Georgetown University Medical School
Washington, D.C.
www.lafebervet.com
Coronal View in Relation to Facial Structure
Normal Sinus CT Scan through the OMU

Eyeball

Ethmoid sinus

Maxillary sinus
Nasal cavity
 Nasal Polyp

www.entusa.com
 Rhinosinusitis
More accurate term than“sinusitis since almost always
preceded by or concomitant symptoms of rhinitis
Acute – Up to 4 weeks
Subacute – 4 to 12 weeks
Chronic – > 12 weeks
Acute vs. Chronic Rhinosinusitis
Usually very different conditions.

Acute rhinosinusitis usually related to infection.

Chronic rhinosinusitis usually related to inflammation.

 Acute Rhinosinusitis
1 billion viral URIs each year

0.5% - 2% lead to secondary bacterial infection of the

sinuses.1,2

Acute bacterial rhinosinusitis often present when

symptoms have not resolved after 10 days or worsen
after 5 to 7 days

1Gwaltney Clin Infect Dis 1996;23:1209

2Berg et al. Rhinology 1986;24:223-5
 Diagnosis of Acute Bacterial
Rhinosinusitis
Acute clinical pattern
Symptoms >10 days and < 28 days
Objective confirmation either / or
Nasal exam documenting purulent d/c beyond the nasal
vestibule
Rhinoscopy
Endoscopy
Posterior pharyngeal drainage
CT scan Not recommended for routine
management
May be helpful in complex cases

Meltzer et al. JACI 2004;114:155

 Diagnosis of Acute Rhinosinusitis:
2 major OR 1 major & 2 minor symptoms

Major Minor
Anterior or posterior Head ache
purulent drainage Ear pain/pressure
Nasal obstruction
Halitosis
Facial pain or pressure or
congestion dental pain
Hyposmia or anosmia Fatigue
Fever (acute) Cough

JACI 2004
Obstruction of the OMU with Associated
Acute Sinusitis

Sinusitis in the
ethmoid sinus.

Sinusitis in the
maxillary sinus.
 Local Factors Predisposing to
Rhinosinusitis
Allergic rhinitis Foreign body

 URI Trauma

 Anatomic abnormalitiy: Barotrauma

 Deviated septum Diving, swimming
 Concha bullosa
 Enlarged adenoids Smoke
 Haller cells
Topical decongestant abuse
 Nasal polyps Nasal intubation
 Tumor
Systemic Factors Predisposing to
Rhinosinusitis
Immune deficiency
IgA deficiency
Panhypogammaglobulinemia
IgG subclass deficiency
HIV
Cystic fibrosis
Ciliary disorder
Granulomatosis with Polyangiitis (Wegener’s)
Gastroesophageal reflux
Complications of Rhinosinusitis
Meningitis
Orbital cellulitis (ethmoid)
Subdural/epidural empyema (frontal)
Brain abscess (frontal)
Cavernous sinus thrombosis (sphenoid)
Osteomyelitis (frontal)
Asthma exacerbation
Treating acute rhinosinusitis: Comparing efficacy and safety of mometasone furoate nasal
spray, amoxicillin, and placebo

Eli O. Meltzer, MD, Claus Bachert, MD, PhD and Heribert Staudinger, MD

Volume 116, Issue 6, Pages 1289-1295

Copyright © 2005 American Academy of Allergy, Asthma and Immunology

 Fig 1

Source: Journal of Allergy and Clinical Immunology 2005; 116:1289-1295 (DOI:10.1016/j.jaci.2005.08.044 )

Copyright © 2005 American Academy of Allergy, Asthma and Immunology

Antibiotics for Acute Sinusitis
Cochrane Database Review (2004) Peds
Available evidence suggest that antibiotics given for 10
days will reduce the probability of persistence in the
short to medium-term.

Cochrane Database Review (2004) Adults

Current evidence is limited but supports the use of
antibiotics for 7 to 14 days
Weigh the moderate benefits of abx treatment against
the potential for adverse effects
Acute Bacterial Rhinosinusitis:
Which antibiotic to use?
No randomized, placebo-controlled trials of antibiotic
treatment for ABRS using pre-and post-treatment sinus
aspirate culture
 Antibiotics
20 to 30% of S. pneumoniae are penicillin resistant
30 to 40% of H. influenzae and 75 to 95% of M.
catarrhalis are beta-lactamase positive
When choosing abx consider
Recent abx use (within 6 weeks)
Severity of disease
 Antibiotics for Acute
Rhinosinusitis
“3. Amoxicillin-clavulanate rather than amoxicillin
alone is recommended as empiric antimicrobial
therapy for ABRS in children (strong, moderate).

4. Amoxicillin-clavulanate rather than amoxicillin

alone is recommended as empiric antimicrobial
therapy for ABRS in adults (weak, low)”.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis

in Children and Adults-2012
 IDSA Clinical Practice Guideline for Acute Bacterial
Rhinosinusitis in Children and Adults
-2012

“7. Macrolides (clarithromycin and azithromycin) are not

recommended for empiric therapy due to high rates of
resistance among S. pneumoniae (∼30%) (strong,
moderate)”.
IDSA Clinical Practice Guideline for Acute Bacterial
Rhinosinusitis in Children and Adults
-2012

“8. Trimethoprim-sulfamethoxazole (TMP/SMX) is not

recommended for empiric therapy because of high
rates of resistance among both S. pneumoniae and
Haemophilus influenzae (∼30%–40%) (strong,
moderate)”.
IDSA Clinical Practice Guideline for Acute Bacterial
Rhinosinusitis in Children and Adults
-2012

“9. Doxycycline may be used as an alternative

regimen to amoxicillin-clavulanate for initial
empiric antimicrobial therapy of ABRS in
adults…”
 Acute Bacterial Rhinosinusitis:
Duration of Treatment
“14. The recommended duration of therapy for
uncomplicated ABRS in adults is 5–7 days (weak, low-
moderate).

15. In children with ABRS, the longer treatment duration of

10–14 days is still recommended (weak, low-moderate)”.

IDSA Clinical Practice Guideline for Acute Bacterial

Rhinosinusitis in Children and Adults- 2012
 Shortcut to acute sinusitis micro.lnk

Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg

2004:130:1
Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1
 Fig 1

Journal of Allergy and Clinical Immunology 2013; 132:1230-1232

Copyright © 2013 American Academy of Allergy, Asthma & Immunology
Chronic Rhinosinusitis
 Diagnosis of Chronic
Rhinosinusitis
Symptoms for > 12 weeks
Two main subtypes:
CRS without nasal polyps
CRS with nasal polyps
Strongly associated with asthma and
aspirin tolerance

Meltzer et al. JACI 2004;114:155

 Clinical Pathologic
CRS without NP CRS with NP
Differences

Asthma Lower Higher

ASA sensitivity Lower Higher
Inflammatory Infilt Mostly PMN’s Mostly EOS
VCAM and IL5 Low High
Mucus MCP Mildly increased Very High
Local IgE prod. Little/unclear Lot
Anti-Staph Toxin Rare Common (>50%)
Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998
 Chronic Rhinosinusitis: Risk
Factors for Extensive Disease
80 patients with CRS

Factors
Eosinophil > 200/uL (OR=19.2, 95% CI=5.4-72.7
Asthma (OR=6.8, 95%CI=2.2-22)
Atopy (OR=4.3,95%CI=1.5-12.8)
Age>50 (OR=6.5,95%CI=2.0-22.2)

Hoover GE et al. JACI 1997;100:185-91

 Prevalence of Allergy in CRS
Chart review of 113 sinus surgery patients

48 patients included in the study

Allergy testing by RAST or skin testing

57.4% had a positive allergy test

Guman et al. Otolaryngol Head Neck Surg 2004;130:545

 Type of Allergy Among Sinus
Surgery Patients
Seasonal

Perennial

None

Perennial and
seasonal

Emmanuel et al. Otolaryngol H&N Surg 2000; 123:687 and Ramandan et al. Am J Rhinol 1999;
13:345
 Diagnosis of CRS
Physical examination
Endoscopy or anterior rhinoscopy
Purulent drainage
Edema or erythema of the middle meatus or ethmoid bulla
polyps

Sinus CT scan
Mucosal thickening
Air-fluid level

Meltzer et al. JACI 2004;114:155

Medical Management of Chronic
Rhinosinusitis
Antibiotics

Corticosteroids

Decongestants

Muco-evacuants

Antihistamines

Non-pharmacologic treatment

v
 Microbiology of Chronic
Rhinosinusitis
Not well defined because of differences in culturing
techniques, prior use of abx

S. pneumoniae, H. influenzae, M. catarrhalis

S. Aureus, coagulase negative staph, anaerobes

Fungi

Meltzer et al. JACI 2004;114:155

 Chronic Rhinosinusitis:
Which Antibiotic to Use?

-No antibiotic is approved by FDA for CRS

-We use similar abx as ABRS

 Antibiotics for Chronic
Rhinosinusitis
Appropriate duration is not well defined
AAAAI and ACAAI Joint Task Force
treat for 3,4 or 6 weeks
continue abx for at least 1 week after the patient is
symptom free

Task Force on Rhinosinusitis of the American

Academy of Otolaryngology-Head and Neck
Surgery
treat 4 to 6 weeks
 Adjunctive Therapy
Decongestants
Used as adjuvant treatment
no controlled studies

Mucolytic treatment
1 double blinded study
2400 mg of guaifenesin or placebo in HIV+ with chronic
sinusitis
improvement in congestion and thick secretions

Wawrose et al. Laryngoscope 1992;102:1225

 Adjunctive Therapy
Antihistamines
play a role in allergic rhinitis patients with sinusitis

Saline irrigation
may help mucociliary clearance
mild vasoconstrictor of nasal blood flow

Intravenous immune globulin

indicated in patients with impaired humoral
immunity
Surgery for Rhinosinusitis
FESS
enlarge sinus ostia
correct anatomic deformities (septal deviation, concha
bullosa)
create a common cavity for nasal drainage
ventilate sinuses
>85% improvement in selected series
 Summary
Acute rhinosinusitis is usually related to infection
Antibiotic management is first line
Chronic rhinosinusitis is usually related to
inflammation
Further characterization of the condition is
important (nasal polyps)
Exploration of underlying allergy is important
Management is challenging