Definition
A.Inflammation of the nasal cavity and paranasal sinuses.
B.Preferred terminology: Rhinosinusitis
rather than sinusitis
since inflammation of the sinuses rarely occurs without inflammation of the nasal mucosa as well.
C.Classification.
1.Acute rhinosinusitis (ARS): Symptoms lasting less than 4 weeks.
2.Acute bacterial rhinosinusitis (ABRS): ARS with bacterial etiology.
3.Chronic rhinosinusitis (CRS): Symptoms lasting greater than 12 weeks.
Incidence
A.Viral infection due to rhinopharyngitis (common cold) is the most common cause of ARS.
B.Annually, 1 in 7-8 persons in the United States will experience an episode of ARS.
C.More frequent in women.
D.Higher in 45- to 64-year -ld age group.
E.ABRS accounts for less than 2% of the cases of ARS.
Pathogenesis
A.Viral.
1.Rhinovirus.
2.Influenza virus.
3.Parainfluenza virus.
B.Bacterial.
a.Streptococcus pneumoniae.
b.Haemophilus influenzae.
c.Moraxella catarrhalis.
Predisposing Factors
A.Older age.
B.Smoking.
C.Air travel.
D.Exposure to changes in atmospheric pressure.
E.Asthma and allergies.
F.Swimming.
G.Dental disease.
H.Immunodeficiency.
Subjective Data
A.Common complaints/symptoms.
1.Nasal congestion.
2.Nasal discharge.
3.Facial pressure or feeling of fullness.
4.Reduced sense of smell.
B.Other complaints.
1.Fatigue.
2.Headache.
3.Difficulty sleeping.
4.Toothache.
5.Ear pain or fullness.
C.Family and social history.
1.Family and social history is noncontributory.
D.Common/typical scenario.
1.Common complaints are:
a.Fever.
b.Sore throat.
c.Nasal discharge.
d.Facial pain.
e.Frontal pain or pressure that worsens when patient bends forward.
2.Patients frequently complain of headaches.
E.Review of systems.
1.Past medical history.
a.Recent illnesses. Elicit onset and duration of symptoms.
b.Sick contacts. Determine if patient or close contacts have any systemic illnesses.
c.Asthma.
2.Allergies.
3.Possible occupational exposure history.
4.Travel history.
5.Pertinent systems review.
a.Constitutional.
i.Fever.
ii.Malaise.
b.Head, ear, eyes, nose, and throat (HEENT).
i.Sinus pain/tenderness.
ii.Headache.
iii.Nasal congestion.
iv.Cough.
v.Rhinorrhea.
vi.Purulent discharge with bacterial infection.
Physical Examination
A.Appearance.
1.Erythema and/or edema of involved cheek.
2.Erythema and/or edema of periorbital area.
B.Drainage.
1.Mucopurulent more likely ABRS.
2.Clear more likely viral ARS.
C.Percussion.
1.Increased pain or tenderness of sinuses.
2.Not specific or sensitive test for diagnosis of rhinosinusitis.
D.Transillumination of frontal and maxillary sinuses.
1.Limited diagnostic value.
2.Not specific or sensitive test for diagnosis of rhinosinusitis.
E.Nasal examination.
1.Diffuse mucosal edema.
2.Narrowing of middle meatus.
3.Inferior turbinate hypertrophy.
4.Presence or absence of polyps.
a.Presence may indicate anatomic risk for development of ABRS.
Diagnostic Tests
A.Generally not indicated for uncomplicated cases of rhinosinusitis.
B.Nasal cultures are not useful in the diagnosis of ABRS.
C.Gold standard for culture identification: Sinus aspiration.
1.Reserved for complicated cases.
2.Referral to otolaryngologist.
D.CT.
1.Persistent symptoms.
2.Recurrent symptoms.
3.Complicated ABRS.
4.Planning for sinus surgery.
Differential Diagnosis
A.Rhinosinusitis.
B.Allergic rhinitis.
C.Rhinopharyngitis.
D.Headache.
Evaluation and Management Plan
A.General plan.
1.Use pain relief: Over-the-counter (OTC) analgesics and antipyretics.
2.Reduce mucosal inflammation: Topical nasal corticosteroids.
3.Enhance sinus drainage: Saline irrigation.
4.Modulate environmental triggers.
a.Treat concurrent allergic rhinitis symptoms if present with OTC antihistamines and allergy therapy as needed.
5.Eradicate infection indicated for ABRS.
B.Patient/family teaching points.
1.Use handwashing to prevent spread.
C.Pharmacotherapy.
1.Acute sinusitis.
a.Most cases of acute sinusitis are viral and pharmacotherapy is targeted to symptomatic relief.
i.OTC analgesics and antipyretics.
ii.Saline nasal irrigation.
iii.Possibly topical corticosteroids.
1)Literature suggests that high-volume corticosteroid irrigations are more effective than low-volume corticosteroid sprays.
iv.Topical decongestants.
1)Use not to exceed 3 to 5 days to avoid rebound congestion.
v.Antihistamines.