Rhinosinusitis
Updated guidelines for acute and chronic varieties
by Susan Waserman, MD
Vol.19, No.06, August 2011

An estimated 2.6 million cases of rhinosinusitis (RS) occur in Canada annually. Acute bacterial rhinosinusitis (ABRS) develops as a complication in 0.5%-2% of upper respiratory tract infections.1 The reported prevalence of chronic rhinosinusitis (CRS) in Canadian households is 15%. Recent publication of the Canadian Clinical Practice Guidelines for Acute and Chronic Rhinosinusitis2 provides the most up-to-date information for first-line practitioners to appropriately diagnose and manage this common condition.

Because nasal and sinus cavities share a common respiratory epithelium, rhinitis (inflammation of the nasal mucosa) and sinusitis (inflammation of a sinus) are often associated, hence the term rhinosinusitis. The reported prevalence of chronic rhinosinusitis (CRS) in Canadian households is 5%.3 RS has a significant impact on quality of life, work productivity/absenteeism, and healthcare spending. Canadians with CRS have reported their health status as being similar to patients with chronic diseases such as cancer, asthma, and inflammatory bowel disease.4 Accurate diagnosis of RS is challenging, but very important, as it has implications for pathophysiology, treatment and prognosis. The following is an overview of salient points from the guidelines on ABRS and CRS.

Acute bacterial rhinosinusitis

ABRS is diagnosed on clinical grounds using symptoms and signs of more than 7 days’ duration. An acute upper respiratory illness of less than 7 days’ duration is typically viral, whereas ABRS becomes more likely beyond one week of persistent or worsening symptoms. An ABRS episode usually lasts less than 4 weeks, and symptoms resolve with or without treatment. Minor symptoms (headache, halitosis, fatigue, dental pain, cough and ear pain/pressure) may be clinically helpful, but only major symptoms are used for the diagnosis (Table 1).5-8 The guidelines introduce the mnemonic PODS for the major symptoms. Radiographic imaging, transillumination, and nasal culture are not recommended for diagnosing uncomplicated ABRS.

Patients with signs of systemic toxicity, altered mental status, severe headache, orbital swelling or change in visual acuity should be immediately referred. Extension of disease beyond the sinuses is a medical emergency. Such cases require urgent assessment by an otolaryngologist, aggressive medical therapy and potential surgery.

Major pathogens in ABRS include S. pneumoniae and H. influenza, while Moraxella catarhallis (more common in children9) and S. aureus are minor pathogens, and anaerobic organisms predominate in acute sinusitis of odontogenic origin.10

Steroids or antibiotics?

The role of antibiotic therapy in ABRS is controversial. Although antibiotics may improve rates of symptom resolution, overall response rates are similar whether patients receive antibiotics or not. Thus, treatment recommendations depend upon symptom severity. In individuals with mild or moderate symptoms and unaffected quality of life, antibiotics can be withheld. In these cases, topical intranasal corticosteroids (INCS) can be useful as sole therapy. For patients with severe symptoms, significant comorbidities, or impaired quality of life, antibiotic therapy is recommended.

When antibiotics are prescribed, amoxicillin is the first line. In beta-lactam allergic patients, trimethoprim-sulfamethoxazole combinations or a macrolide antibiotic may be substituted. Use second-line therapy with enhanced Gram-positive activity — amoxicillin/clavulanic acid combinations or quinolones in patients at risk of complications due to underlying disease, potential bacterial resistance, or treatment failure with first-line therapy (i.e., no response within 72 hours). Antibiotic choice also depends upon local antibiotic resistance patterns and factors that suggest penicillin- and macrolide-resistance (i.e., antibiotic exposure in previous 3 months, chronic symptoms, or parents of kids in daycare). For uncomplicated ABRS in otherwise healthy adults, different antibiotics show comparable efficacy. Ten days of antibiotic therapy is sufficient.

Analgesics, oral and topical decongestants, topical INCS, and saline sprays or rinses can help relieve symptoms of viral and bacterial infections.

Refer patients to a specialist if symptoms of ABRS persist despite appropriate therapy, as well as for severe ABRS, frequent recurrences (> 3 per year), nosocomial infections, immunocompromise, anatomic obstruction, and for allergy evaluation or biopsy. Referral for allergy or immune function testing isn’t required for isolated episodes.

Discuss preventative strategies, such as handwashing, with patients to reduce the risk of acute viral infection, the most common antecedent to ABRS.

Chronic rhinosinusitis

CRS is diagnosed on clinical grounds with confirmation by an objective finding. Diagnostic criteria are presented in Table 2.7,8,11 CRS subtypes include CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP).12 Both types are characterized by mucopurulent drainage and nasal obstruction. Facial pain/pressure is more common in CRSsNP, while hyposmia (a reduced sense of smell) is often present in CRSwNP.

Physical examination of the nasal cavity (an otoscope is adequate) should be performed on any individual with chronic nasal symptoms. Healthy, hydrated mucosa is pinkish-orange with a slight sheen. An irregular mucosal surface, crusts, diffusely hemorrhagic areas, or bleeding in response to minimal trauma are abnormal and should prompt specialist referral. Nasal polyps and purulent nasal secretions can be visualized between the septum and the lateral wall of the nose, in the middle meatal area. Routine cultures including nasal swab of secretions are not recommended.

CRS is an inflammatory disease where bacterial colonization may contribute to pathogenesis by stimulation of immune responses that lead to inflammation. The main pathogens in CRS include S. aureus, Enterobacteriaceae spp and Pseudomonas spp. Intense inflammation, especially with eosinophils, has been documented in CRS biopsies, however, bacterial cultures are often negative. Allergic rhinitis, asthma, ciliary dysfunction, immune dysfunction, aspirin-exacerbated respiratory disease, defective mucociliary clearance, decreased ostial patency and cystic fibrosis have been associated with, or predispose to CRS. But the exact roles played by triggers, environmental factors and host susceptibility remain uncertain.

CRSsNP is managed with nasal or oral corticosteroids and oral antibiotics, as bacterial infections are thought to contribute to this condition. Empiric antibiotic therapy is broader spectrum than for ABRS, and should target enteric Gram-negative organisms, S. aureus and anaerobes as well as common encapsulated organisms associated with ABRS (S. pneumoniae, H. influenzae, M. catarrhalis). Amoxicillin-clavulanic acid and fluoroquinolones (such as moxifloxacin) have broad-spectrum coverage. Duration of antibiotic treatment is longer than for ABRS. Long-term (3 months) treatment with low-dose macrolides (e.g., clarithromycin) also has been reported to improve symptoms.13-16

CRSwNP is managed with topical intranasal corticosteroids (INCS) and short courses of oral steroids. Concurrent oral antibiotic therapy is indicated only if symptoms of infection, such as pain, recurrent episodes or documented purulence are present.

INCS is indicated only if symptoms of infection such as pain are present, or for recurrent episodes or documented purulence. INCS relieve nasal congestion and shrink nasal polyps; actions that are attributed to their anti-inflammatory properties. Although studies demonstrate the efficacy of INCS in CRSwNP,17-21 results are less consistent for patients with CRSsNP. Nevertheless, INCS are recommended for all patients, as both subtypes of CRS have a large inflammatory component.

Treatment alternatives

Saline irrigation has been shown to relieve symptoms of CRS.22 Other adjunct therapies, such as mucolytics and antihistamines, haven’t been evaluated in CRS but may help symptoms. Oral decongestants have also not been well studied in CRS and long-term use is not recommended, similarly for topical decongestants. Prolonged use of topical decongestants isn’t recommended either.23

If a patient fails to respond to treatment, then recommended actions include:

  • Consideration of other possible diagnoses (allergic, non allergic or vasomotor rhinitis, allergic fungal RS, invasive fungal RS, nasal septal deviation, atypical facial pain, migraine or other headache, temporomandibular joint dysfunction and trigeminal neuralgia)7
  • Investigation with CT scan
  • Referral to an otolaryngology specialist

Patients with CRS should be referred to a specialist in the event they fail one or more courses of maximal medical therapy or have > 3 infections per year. Urgent consultation is required for those with severe symptoms of pain/swelling, or on immunosuppression. Allergy testing is recommended to identify triggers that might respond to treatment. Immune function testing is not required in uncomplicated cases.

Endoscopic sinus surgery (ESS) may be indicated in cases of treatment failure and has been shown to be beneficial. ESS clears diseased mucosa, relieves obstruction and restores ventilation. Ongoing medical therapy after surgery is required for all patients and consists of topical/oral corticosteroids, saline irrigation and antibiotics where indicated.24

Discuss preventative measures with your patients, including allergen avoidance/treatment where relevant, proper hand hygiene to minimize viral infection, smoking cessation and nasal saline irrigation.

Rhinosinusitis is a prevalent condition with significant effects on patient quality of life, work productivity and healthcare spending. Diagnosis isn’t always straightforward. The Canadian guidelines (which may be accessed at www.aacijournal.com/content/7/1/2) provide up-to-date evidence-based recommendations, as well as expert opinion on the diagnosis and management of RS. They include practical tools, such as diagnostic and treatment algorithms, to help first-line practitioners improve the lives of their patients affected by rhinosinusitis.

(The images in this article are from the Rhinosinusitis Image Library, which is available at www.sinuscanada.com — password sinus. You are welcome to visit the website for images, videos and educational materials.)

Susan Waserman, MD, FRCPC is Professor of Medicine in the Division of Clinical Immunology and Allergy, Department of Medicine, at McMaster University, Hamilton, ON.
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Uncomplicated mild-moderate ABS
(Photos: Dr Marc A. Tewfik/Rhinosinusitis Image Library)

References

1. Gwaltney JM, Jr. Clin Infect Dis. Dec 1996;23(6): 1209-23; quiz 1224-5.

2. Desrosiers M, et al. Allergy Asthma Clin Immunol. 2011;7(1):2.

3. Chen Y, et al. Laryngoscope. Jul 2003;113(7): 1199-1205.

4. Macdonald KI, et al. Laryngoscope. Jan 2009;119(1): 184-9.

5. Fokkens W, et al. Rhinol Suppl. 2007(20):1-136.

6. Hickner JM, et al. Ann Emerg Med. Jun 2001;37(6):703-10.

7. Rosenfeld RM, et al. Otolaryngol Head Neck Surg. Sep 2007;137 (3 Suppl):S1-31.

8. Scadding GK, et al. Clin Exp Allergy. Feb 2008; 38(2):260-75.

9. Wald ER. J Allergy Clin Immunol. Sep 1992;90(3 Pt 2):452-6.

10. Brook I. J Clin Microbiol. Jul 2005;43(7):3479-80.

11. Slavin RG, et al. J Allergy Clin Immunol. Dec 2005;116 (6 Suppl):S13-47.

12. Meltzer EO, et al. J Allergy Clin Immunol. Nov 2006;118 (5 Suppl):S17-61.

13. Hashiba M, et al. Acta Otolaryngol Suppl. 1996; 525:73-8.

14. Ichimura K, et al. Auris Nasus Larynx. 1996;23: 48-56.

15. Ragab SM, et al. Laryngoscope. May 2004;114(5): 923-30.

16. Wallwork B, et al. Laryngoscope. Feb 2006; 116(2):189-93.

17. Filiaci F, et al. Rhinology. Dec 2000;38(4):185-90.

18. Jankowski R, et al. Arch Otolaryngol Head Neck Surg. Apr 2001;127(4):447-52.

19. Small CB, et al. J Allergy Clin Immunol. Dec 2005; 116(6):1275-81.

20. Stjarne P, et al. Acta Otolaryngol. Jun 2006; 126(6):606-12.

21. Stjarne P, et al. Arch Otolaryngol Head Neck Surg. Feb 2006;132(2):179-85.

22. Harvey R, et al. Cochrane Database Syst Rev. 2007(3):CD006394.

23. Graf P, et al. Arch Otolaryngol Head Neck Surg. Oct 1999;125(10):1128-32.

24. Desrosiers MY, et al. Rhinology. Mar 2008; 46(1):3-14.

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