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Toronto Notes 2019
Rhinosinusitis
Otolaryngology OT25
Table 13. Etiologies of Rhinosinusitis
Ostial Obstruction
Systemic
Direct Extension
Inflammation Mechanical
Immune
Dental Trauma
URTI Allergy
Septal deviation
Turbinate hypertrophy
Polyps
Tumours
Adenoid hypertrophy
Foreign body
Congenital abnormalities (e.g. cleft palate)
PA
Lymphoma, leukemia
Immunosuppressed patients (e.g. neutropenics, diabetics, HIV)
Cystic fibrosis
Immotile cilia (e.g. Kartagener’s)
Infection
Facial fractures
Acute Bacterial Rhinosinusitis
Definition
• bacterialinfectionoftheparanasalsinusesandnasalpassageslasting>7d
• clinicaldiagnosisrequiring≥2majorsymptoms,andatleastoneofthesymptomsiseithernasal
Acute Rhinosinusitis Complications
Consider hospitalization if any of the following are suspected
Orbital (Chandler’s classification)
• Preseptal cellulitis
• Postseptal cellulitis
• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
Intracranial
• Meningitis
• Abscess
Bony
• Subperiosteal frontal bone abscess (“Pott’s
Puffy tumour”)
• Osteomyelitis
Neurologic
• Superior orbital fissure syndrome (CN III/
IV/VI palsy, immobile globe, dilated pupils,
ptosis, V1 hypoesthesia)
• Orbital apex syndrome (as above, plus
neuritis, papilledema, decreased visual acuity)
Systemic Corticosteroid Therapy for Acute Sinusitis
JAMA. 2015 Mar;313(12):1258-9.
Clinical Question: Are oral or parenteral corticosteroids associated with improved clinical outcomes in patients with acute sinusitis compared with placebo or NSAIDs?
Conclusion: Oral corticosteroids combined with antibiotics may be associated with modest benefit for short-term relief of symptoms in adults with severe symptoms of acute sinusitis compared
with antibiotics alone. Oral corticosteroids as monotherapy are not associated with improved clinical outcomes in adults with clinically diagnosed acute sinusitis.
obstruction or purulent/discoloured nasal discharge
Major Symptoms (at least 2 of PODS, 1 must be O or D) P Facial Pain/Pressure/fullness
O Nasal Obstruction
D Purulent/discoloured nasal Discharge
S Hyposmia/anosmia (Smell)
Etiology
Minor Symptoms
Headache Halitosis Fatigue Dental pain Cough
Ear pain/fullness
• bacteria:S.pneumoniae(35%),H.influenzae(35%),M.catarrhalis,S.aureus,anaerobes(dental)
• childrenaremorepronetoabacterialetiology,butviralisstillmorecommon
• maxillarysinusmostcommonlyaffected
• mustruleoutfungalcauses(mucormycosis)inimmunocompromisedhosts(especiallyifpainlessblack
or pale mucosa on examination)
Clinical Features
• suddenonsetof:
■ nasal blockage/congestion and/or purulent nasal discharge/posterior nasal drip ■ ± facial pain or pressure, hyposmia, sore throat
• persistent/worseningsymptoms>5-7dorpresenceofpurulencefor3-4dwithhighfever
• speculumexam:erythematousmucosa,mucopurulentdischarge,pusoriginatingfromthemiddle
meatus
• predisposingfactors:viralURTI,allergy,dentaldisease,anatomicaldefects
• differentiatefromacuteviralrhinosinusitis(course:<10d,peaksbyday3)
Diagnosis
• alongwithclinicalcriteria,canconfirmradiographicallyand/orendoscopicallyusingantralpuncture for bacterial cultures
Management
• dependsonsymptomseverity(i.e.intensity/durationofsymptoms,impactonqualityoflife)
• mild-moderate: INCS
■ if no response within 72 h, add antibiotics
• severe:INCS+antibiotics
• antibiotics
■ 1st line: amoxicillin x 10 d (TMP-SMX or macrolide if penicillin allergy)
• if no response to 1st line antibiotics within 72 h, switch to 2nd line
■ 2nd line: fluoroquinolones or amoxicillin-clavulanic acid
• adjuvanttherapy(salineorhypochlorousacid(pediatricsinusitis)irrigation,analgesics,oral/topical
decongestant) may provide symptomatic relief
• CTindicatedonlyifcomplicationsaresuspected