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Sinusitis
From WikEM
Contents
Background
- Acute (<4 weeks)
- Acute viral
- Acute bacterial (0.5-2% of cases)[1]
- Subacute (4-12 weeks)
- Chronic (>12 weeks)
- Other causes
- Fungal infections
- Allergies
Clinical Features
- Defined as 2 or more of the following:
- Blockage or congestion of nose
- Facial pain or pressure
- Hyposmia (diminished ability to smell)
- Anterior or posterior nasal discharge lasting <12wk
- Additional symptoms:
- Tooth pain
- Fever
- Sinus pressure while bending forward to changing head position
Differential Diagnosis
- Migraine
- Craniofacial neoplasm
- Foreign body retention
- Dental caries
Evaluation
- Consider CT only for toxic patients (to rule-out complication)
Management
<10 days of symptoms
- Symptomatic treatment b/c most likely viral
- Analgesia
- Mechanical irrigation with buffered, hypertonic saline
- Topical glucocorticoids - Flonase
- Dexamethasone 10mg PO x1 dose
- Zicam
- Topical decongestants (e.g. oxymetazoline for no more than 3d)
- Antihistamines
- Mucolytics
- Avoid antibiotics
- Part of ACEP Choosing wisely
>10 days of symptoms
- Suspicious for bacterial origin especially with:
- No clinical improvement after 10 days
- Severe symptoms or high fever and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness
- Onset with newly worsening that were initially improving (‘‘doublesickening’’)
- Acute bacterial sinusitis[2]
- First line is amoxicillin-clavulanate (over amoxicillin alone) for 5-7 days, not 10-14
- Second line is fluoroquinolone or doxycycline
IDSA Guidelines 2012[3]
- Highlights identifying factors for acute bacterial vs. viral rhinosinusitis
- Treat with antibiotics if any of these:
- Purulent discharge and pain on face or teeth > 10 days without improvement
- Severe symptoms or fever > 39 plus symptoms > 3 days
- "Double sickening" - sinusitis symptoms at end of initially improving URI that lasted > 5 days
Antibiotic Failure
- Obtain culture
- Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
- Consider foreign body
- Consider fungal treatment
Disposition
- Typically outpatient
Complications
- Meningitis
- Cavernous sinus thrombosis (ethmoid/sphenoid)
- Intracranial abscess
- Orbital cellulitis (ethmoid)
- Frontal bone osteomyelitis (Pott's puffy tumor)
- Extradural or subdural empyema
See Also
References
- ↑ Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar;(23):3 p preceding table of contents, 1-298
- ↑ Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. IDSA Guidelines. 2012; Clinical Infectious Diseases e1-e41.
- ↑ Chow AW et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Disease (2012) 54:e72-112.
