Rhinosinusitis

Review for resident I

4 Aug 2015

 Rhinosinusitis
Symptomatic inflammation of mucosal lining of
the paranasal sinuses and nasal cavity

Uncomplicated rhinosinusitis
Rhinosinusitis without clinically evident extension
of inflammation outside the paranasal sinuses and
nasal cavity at the time of diagnosis

Prevalence of pathogen in acute rhinosinusitis

Virus 90-98%
Bacteria 2-10%

ARS definition (AAO-HNS)

ABRS definition (IDSA)

Any of 3
Onset with persistent symptoms or signs compatible
with acute rhinosinusitis, lasting for >/= 10 days
without any evidence of clinical improvement
Onset with severe symptoms or signs of high fever
(>/= 39C) and purulent nasal discharge or facial pain
lasting for at least 3-4 consecutive days at the
beginning of illness
Onset with worsening symptoms or signs characterized
by the new onset of fever, headache, or increase nasal
discharge following a typical URI that lasted 5-6 days
and were initially improving (double sickening)

Rhinosinusitis definition
(EPOS)
Two of more symptoms, one of which should be
either nasal blockage or nasal discharge
(anterior/posterior nasal drip)
+/-facial pain/pressure
+/-reduction or loss of smell

And either
Endoscopic signs of :
Nasal polyps, and/or
Mucopurulent discharge from middle meatus and/or
Edema/mucosal obstruction primarily in middle meatus

And/or

 CT changes:
Mucosal changes within the osteomeatal
complex and/or sinuses

Acute (< 12 wk) Vs chronic (>/= 12

wk)

CRS definition (AAO-HNS)

Symptom prevalence by day for

rhinovirus illness

0.5-2% of VRS ABRS

Watchful waiting (no ATB) for ABRS?

Definition : defering ATB for upto 7 days after diagnosis
Assurance of F/U
Exclude
Complicated rhinosinusitis
Immunodeficiency
Coexisting bacterial illness
+/- patients age, general health, cardiopulmonary status and
comorbid conditions
+/- severe case (severe symptoms at the onset or high fever
(>39C) and purulent discharge or facial pain lasting at
least 3 to 4 consecutive days at the beginning of illness)
Not recommend in IDSA

Choice and duration of ATB for ABRS

*Amoxicillin (+/- clavulanate)*
Penicillin allergy
Type I : doxycycline, respiratory
quinolone (levofloxacin, moxifloxacin)
Non-type I : clindamycin + third
generation cephalosporin

Not more than 10 days (short courses

5-7 days maybe considered in less
severe illness)

Factor to consider plus

clavulanate

High dose amoxicillin

4 g/day or 90 mg/kg/day (divide twice daily)
Cover penicillin nonsusceptible (PNS)
S. pneumoniae (PBP3 mutation)
High endemic area (>10%)
Severe infection
Age <2, > 65
Attendance at daycare
Recent hospitalization
Recent antibiotic within the past months
Immunocompromised

Initial treatment failure

Failure to improved
Lack of reduction in presenting signs/symptoms by 7
days

Worsening
Progression of presenting signs/symptoms or onset of
new signs/symptoms

Shorter period in IDSA guideline

Re-evaluate
Endoscopic guided C/S from middle meatus (drug
resistant bacteria?)
Other diagnosis?
Complication?

ATB in adult ABRS

ATB in children ABRS

Imaging
Unnecessary for diagnoses ABRS
Obtain when complication (soft
tissue, orbital or intracranial) is
suspected
CT is proper in most cases (MRI in
selected cases)

Modifying factors
Asthma
Cystic fibrosis (less common in
Thailand)
Immune status
Ciliary dyskinesia
Anatomic variation

Summary of evidence-based
statements

Summary of evidence-based
statements

AAO-HNS

IDSA

CRS
CRS with nasal polyps (CRSwNP)
CRS and bilateral, endoscopically
visualised polyps in middle meatus

CRS without nasal polyps (CRSsNP)

CRS and no visible polyps in middle
meatus

References
Clinical practice guideline : adult
sinusitis (AAO-HNS, 2015)
Clinical practice guideline for acute
bacterial rhinosinusitis in children
and adults (IDSA, 2012)
European positional paper on
rhinosinusitis and nasal polyps
(EPOS, 2012)