Acute sinusitis (rhinosinusitis)


One of the 10 most common diagnoses in ambulatory medicine.

Most upper respiratory tract infections (URTIs) are viral and more common in children than adults.

Affects 1 in 7 adults, resulting in approximately 31 million individuals receiving this diagnosis each year.

Most URTIs are self limited, but up to 50% of all patient encounters for viral UTTI may result in an antibiotic prescription.

Among the most common reasons for physician consultation and antibiotic prescriptions.

Estimated 20 million cases of rhinosinusitis diagnosed in the US. annually.

Fifth most common US diagnosis for which an antibiotic is prescribed.

Anñual cost $2 billion/year in costs.

Acute facial pain, pressure, congestion and fullness, c) nasal obstruction, blockage, discharge, and purulence, d) fever, d) hyposmia and anosmia.

Minor factors: a) headache, b) fever c) halitosis, c) fatigue, d) dental pain, e) cough, f) ear pain and fullness.

Diagnosis of acute rhinosinusitis is based in the presence of nasal congestion, purulent rhinorrhea with post nasal discharge and facial pain/pressure.

The use of transillumination and facial palpation for tenderness does not improve diagnostic accuracy.

Among the most common reasons for physician consultation and antibiotic prescriptions.

Symptoms resolve spontaneously in most patients and symptomatic treatment and watchful waiting is most appropriate in patients with mild disease.

Antibiotics should be prescribed for patients with severe symptoms

May last as long as 4 weeks.

Recurrent acute rhinosinusitis refers to four or more episodes of acute rhinosinusitis per year with resolution of symptoms between episodes.

Subacute rhinosinusitis refers to symptoms that have been present for more than four weeks but less than three months.

Diagnosed one in six adults each year.

Up to 20% of affected individuals do not seek medical care.

Fifth most common diagnosis for which an antibiotic is prescribed.

Maxillary sinuses are the most frequently affected sinuses.

Predisposing factors include: allergic rhinitis, anatomic variation, barotraumas. dental infection, exposures to irritants such as smoke, hormonal changes, immunodeficiency and upper respiratory tract infection.

Upper respiratory tract viral infections involve sinusoidal, nasal and oropharyngeal mucosa, so that up to 90% of patients have associated symptoms of rhinosinusitis.

Mild to moderate sinusitis is defined as sinusitis without high temperature, severe pain or tenderness over the involved sinuses.

Viruses cause the majority acute mild to moderate sinus infections.

Most frequent precipitating factors are viral infection and allergic rhinitis.

It is estimated that only 2-10% of the 20 million cases of acute sinusitis that occur annually in US are due to bacterial infection.

Patients with sinus symptoms persisting longer than 10 days after onset are more likely to have a bacterial rhinosinusitis.

Patients who have acute sinusitis and whose symptoms initially improve and then relapse are more likely to have bacterial sinusitis.

Approximately 2.5% of URTI’s in children are complicated by acute bacterial sinusitis.

Antibiotics are prescribed in 85% of patient encounters of childhood sinusitis.

Amoxicillin and amoxicillin and clavulanate are most frequently prescribed antibiotics accounting for 65% of antibiotics prescribed for acute sinusitis in children.

Among children with acute sinusitis treated in an outpatient setting, amoxicillin and clavulanate was associated with more adverse events and no difference in treatment failure risk compared to amoxicillin (Savage T).

Three organisms: Streptococcus pneumonias, non-typeable Hemophilus influenza, and Moraxella catarrhalis account for the majority of acute bacterial sinus cases in children

Radiographic diagnostic imaging shows air fluid levels or mucosal thickening, but such studies are not very accurate and generally not recommended.

Up to 10% of cases caused by periodontal or periapical (the apices of the first, second and third molars reside in the maxillary bone at the floor of the maxillary sinus) disease.

0.5-2% of colds are complicated by acute bacterial sinusitis, yet antibiotics are prescribed for 50% or more of cases.

In children is usually a self-limited disease of short duration and antibiotics offer no clinical benefit.

Acute bacterial sinusitis diagnosis is based on the duration and severity of symptoms of URTI‘s, with the treatment ranging from close observation to a 10 day course of antibiotics.

Most cases of acute bacterial sinusitis do not require an anabiotic.

Antibiotic used in acute bacterial sinusitis shows only modest improvements in duration of symptoms and a median two point reduction in daily symptoms on a 40 point scale, compared with placebo

If caused by a virus antibiotic use is unlikely to be beneficial.

Antibiotic use may be beneficial in bacterial acute sinusitis by health speeding recovery and can prevent complications.

Two most common causes of bacterial infection are Streptococcus pneumonia and Haemophilus influenzae accounting for 50-75 percent of bacterial organisms.

Unlike with chronic sinusitis, less than 10% of cases are associated with anaerobic organisms such as Peptostreptococcus spp, Fusobacterium spp, Prevotella spp and Porphyromonas spp.

At least half of acute sinusitis infection caused by viruses with rhinovirus, parainfluenza and influenza the most common causes.

Headache attributed to sinusitis: in the presence of frontal headache accompanied with pain in 1 or more sites of the face, ears, or teeth, along with evidence for acute or chronic inflammation by clinical or imaging techniques, the development of facial pain with acute exacerbation of rhinosinusitis and resolution of the head/facial pain with treatment of the acute inflammation.

Observational management without antibiotics considered for adults with an uncomplicated and mild infection.

Amoxicillin is the recommended first line treatment for most adults.

A randomized controlled trial of adults with uncomplicated acute rhinosinusitis treated with a 10 day course of amoxicillin compared with placebo did not reduce symptoms at day 3 of treatment: Findings support recommendations of avoiding routine antibiotic treatment for patients with uncomplicated acute rhinosinusitis. (Garbutt JM et al).

Intranasal corticosteroids are recommended for moderate symptomatology as mono therapy and in addition to antibiotics when symptoms are severe.

With severe symptoms systemic corticosteroids may have advantages over topical treatment due to higher corticosteroid levels and lower risk of poor delivery due to nasal secretion interference.

Cochrane review of four studies revealed that oral corticosteroids combined with antibiotics maybe associated with modest benefit (Venekamp RP et al).for the short-term relief of symptoms in adults with severe acute sinusitis compared to antibiotics alone.

In the above review oral corticosteroids as mono therapy was not associated with improved clinical outcomes in adults with clinically diagnosed acute sinusitis.

In a meta-analysis of 2547 adults from nine trials utilizing antimicrobial agents found that 15 patients needed to be treated to cure one patient, even if symptoms lasted beyond seven days (Young J).

Placebo-controlled clinical tri•als to evaluate antibiotics have conflicting results: Studies requiring confirmatory tests such as sinus x-rays show a treatment benefit of antibiotics, but meta-analyses have generally concluded benefits with antibiotic treatment are small due to the high rate of spontaneous improvement of approximately 69%.

Studies using clinical diagnostic criteria can show little or no antibiotic treatment and a pretty and spontaneous resolution rate of approximately 80%.

Fluoroquinolones commonly used to treat bacteria disease as these agents have efficacy for respiratory tract infections.

Fluoroquinolones recommended for patients in whom a drug resistant bacterial infection is suspected or in those who have previously been treated with antibiotics during the previous 4-6 weeks and failing such management.

Fluoroquinolones commonly used to treat bacteria disease as these agents have efficacy for respiratory tract infections.

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