Approximately 31 million adults in the United States suffer from sinusitis.1 Acute sinusitis is the fifth most common diagnosis generating an antibiotic prescription, with an annual cost of $1.77 billion.2 Chronic sinusitis results in 18 to 22 million primary care visits and more than 200,000 surgical procedures each year.1,3 The estimated annual healthcare cost of chronic sinusitis in the United States is $3 to $5 billion.3
Rhinosinusitis is inflammation and/or infection of one or more of the paranasal sinuses (see Paranasal sinuses).4 Rhinosinusitis describes the concomitant inflammation of both the nasal mucosa and paranasal sinuses.5 Rhinosinusitis without extension of inflammation outside the paranasal sinuses and nasal cavity (such as no neurological, ophthalmological, or soft tissue involvement) is termed uncomplicated rhinosinusitis.6 Rhinosinusitis can be classified as acute with a duration of up to 4 weeks, subacute lasting 4 to 12 weeks, and chronic, which lasts 12 weeks and beyond.7 Recurrent acute rhinosinusitis (RARS)is defined as four or more acute episodes per year without persistent symptoms between episodes.4 It is not clear whether RARS is multiple episodes of chronic sinus disease exacerbation or a separate disease category.5
The pathogenesis of acute rhinosinusitis (ARS) can be either viral or bacterial (see Causes of ARS). Viruses such as rhinovirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus are the most common offenders. The viruses come in contact with the nose and are transported posteriorly to the nasopharynx, adhering to cell walls and activating several inflammatory pathways. The result is engorgement of turbinate vasculature, intercellular leakage, and seromucinous discharge, with stimulation of pain nerve endings and the cough reflex.4 Acute bacterial rhinosinusitis (ABRS) is often preceded by a viral upper respiratory infection that extends into the paranasal sinuses.6 Mucosal edema and compromised ventilation of the paranasal sinuses create a favorable environment for bacterial overgrowth.4 The most common community-acquired bacterial organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, other Streptococcus species, and Staphylococcus aureus.4,7,8
Chronic rhinosinusitis (CRS) results from a wide range of inflammatory processes and has multiple causes, including infectious, anatomic, allergic, genetic or congenital mucociliary dysfunction, and systemic disorders (see Causes of CRS).4,7 CRS has an atopic inflammatory response where eosinophils are the predominant inflammatory cells.4,9 Allergic rhinitis is found in 60% of patients with CRS.10
CRS is subdivided into two categories: hypermucosal changes with polyps and without polyps.4 CRS without polyps can develop due to anatomic factors such as blockage of the osteomeatal complex (OMC) from edema and inflammation or turbinate hypertrophy and/or septal deviation, causing stasis of secretions. The OMC is a functional designation for the common drainage zone of the anterior ethmoid, frontal, and maxillary sinuses.7 Mucociliary dysfunction caused by intrinsic factors (such as cystic fibrosis, primary ciliary dyskinesia) or extrinsic factors (such as, injury by environmental irritants) is another cause of CRS without polyps. Biofilms produced by some bacteria such as Pseudomonas aeruginosa can confer resistance to some antibiotics.4,7 CRS with polyps can develop as a result of allergic fungal rhinosinusitis, aspirin-sensitive nasal polyposis (overproduction of leukotrienes), and endotoxins secreted by certain Staphylococcus aureus organisms (staphylococcal superantigen).4,7
Gastroesophageal reflux disease has been considered a possible cause of CRS. It is hypothesized that gastric acid refluxes into the pharynx and nasopharynx causing inflammation of the sinus ostium.4,7,10
A link between CRS with nasal polyps and asthma has also been demonstrated.11 Rhinitis has been identified as an independent risk factor for the development of asthma, and upper-airway infections have been shown to exacerbate asthma.12
History and physical exam
ARS may present with cough, sneezing, rhinorrhea, nasal congestion, facial pain or pressure, headache, and sore throat. Sputum may be clear, colored, or cloudy. Color of sputum is related to the presence of neutrophils and not bacteria.6 Physical exam includes evaluation of nasal mucosa for edema, purulent secretions, and increased blood flow. Palpation of the maxillary and frontal sinuses for tenderness as well as evaluation of the eyes for periorbital edema should be performed. Pharyngeal erythema and lymphoid hyperplasia may also be seen. Ear evaluation should be performed to assess for the presence of middle-ear effusions.8
Common symptoms of CRS include mucopurulent drainage, nasal obstruction, nasal congestion, and postnasal discharge. Generalized facial pain, fullness, and pressure may be reported and can be localized to one side. Olfactory dysfunction is common in CRS. Other less common symptoms include ear pain/pressure, fatigue, cough, and halitosis. Inspection of nasal mucosa for inflammation and edema, as well as the oropharynx for postnasal discharge and evaluation of maxillary dentition should be performed. Palpation of the periorbital, forehead, and cheek areas to evaluate sinus tenderness should be included in the exam in addition to transillumination of the maxillary and frontal sinuses.4,6,8
Figure. Paranasal si...Image Tools
In ARS it can be difficult to distinguish between viral and bacterial causes based on symptomatology; thus, the illness pattern and duration should be used to make the distinction. Viral rhinosinusitis (VRS) is a self-limiting disease characterized by up to 10 days of persistent symptoms. ABRS should be diagnosed when symptoms are persistent for 10 or more days or the symptoms worsen within 10 days after an initial improvement (double worsening).6 Radiographic imaging of the paranasal sinuses is unnecessary for diagnosis in patients who meet the clinical criteria, unless a complication is suspected. Nasal cultures are not reliable for establishing the diagnosis of rhinosinusitis. Maxillary antrum aspiration is definitive but only indicated when microbial identification is essential.8
Nasal endoscopy is part of the evaluation of CRS and RARS in order to visualize the anterior nasal cavity as well as the posterior nasal cavity, nasopharynx, and sinus drainage pathways in the middle and superior meatus.5,6 Coronal CT of the paranasal sinuses should be performed to evaluate CRS or RARS after initial medical therapy.4 CT scans may reveal mucosal thickening and trapped secretions in the paranasal sinuses. Other anatomical variations that may be seen in CRS and RARS are septal deviations, meatal impingement, concha bullosa (pneumatized middle turbinate), and Haller cells (extensions of ethmoid cells into the maxillary sinuses).4,13 Purulent mucus or edema in the middle meatus or ethmoid region, polyps in the nasal cavity, and/or radiographic imaging demonstrating paranasal sinus inflammation along with the signs and symptoms listed above is diagnostic for CRS.6 Testing for allergy and immune function may be obtained as part of the evaluation for CRS and RARS because a relationship between allergic rhinitis and rhinosinusitis has been demonstrated.6,14
Management of VRS is mainly a symptomatic treatment. Analgesics and antipyretics for pain and fever should be recommended.6 Short-term topical or systemic decongestants may offer additional symptomatic relief by reducing mucosal blood flow, decreasing tissue edema and nasal resistance.8 Management of ABRS should include analgesics for pain. In patients with nonsevere illness at presentation (mild pain and temperature less than 101°F [38.3°C]), observation, when follow-up is ensured, is an option. Patients with severe illness (moderate-to-severe pain or temperature greater than 101°F) or those with nonsevere illness that doesn't improve by 7 days are treated with oral antibiotics.6 Amoxicillin is the first-line therapy for most patients. Macrolides and trimethoprim-sulfamethoxazole can be used in patients with a penicillin allergy.6,15 A meta-analysis of three studies found that intranasal corticosteroids used alone or as adjunctive therapy with antibiotics increased symptom response.16 Nasal irrigation with sinus rinses may improve symptoms.15 The patient should be reassessed if the condition worsens or fails to improve within 7 days.6
Management of CRS varies among individuals because of the heterogeneous nature of the disease. The main goal of managing CRS, however, is identifying and treating the underlying cause(s).15 Antimicrobials are used in the treatment of CRS to clear the initial infection and any exacerbations.15 Amoxicillin, amoxicillin/clavulanate, fluoroquinolones, and later-generation cephalosporins are the first-line antibiotic treatment.4 A 3- to 4- week course of antibiotic treatment is usually adequate.4,15 Intranasal corticosteroids have been shown to be efficacious in the treatment of CRS. Oral glucocorticoids are widely used as treatment for CRS especially with nasal polyps; however, there is a lack of placebo-controlled trials to document efficacy.4,12,17 Montelukast is an antileukotriene that has been approved for treating inhalant allergies and may be used as adjunctive therapy for patients with CRS and inhalant allergies.4 Nasal saline irrigation has been shown to eliminate allergens, thin and remove secretions, and reduce postnasal drainage. It is a well-tolerated and inexpensive component of CRS management.4,8,15 Patients with anatomic obstruction who are refractory to medical management may be surgical candidates to allow for sinus ventilation and drainage. Endoscopic sinus surgery is the preferred method.7,15
Management of complications
Table. Causes of CRS...Image Tools
Complications of rhinosinusitis include orbital cellulitis or abscess, optic neuritis, cavernous sinus thrombosis, meningitis, subdural abscess, brain abscess, and frontal bone osteomyelitis. Patients with orbital swelling or pain, swelling of the forehead, visual changes, neurologic symptoms, or change in level of consciousness should be immediately evaluated.4,7,8
Primary prevention of VRS and ABRS includes good hand hygiene and smoking cessation. Nasal saline irrigations are a secondary preventive measure to minimize symptoms of CRS and exacerbations of RARS.6 Although evidence-based research is lacking, observation studies have shown that treatment of gastroesophageal acid reflux has been shown to improve sinus symptoms.4,8
Patients need to be educated about the presentation and course of VRS and ABRS to dispel common misconceptions and reduce antibiotic overuse. A recent study by Li et al. found that patients who received antibiotics in their initial visit for upper respiratory tract infection were as likely to return for a follow-up visit as those who did not receive an antibiotic prescription, thus dismissing the myth that an antibiotic prescription is needed for patient satisfaction.18 Educating patients about development of antibiotic resistance by antibiotic overuse and misuse is important to reduce the incidence of superinfections. Furthermore, patients should be instructed on proper technique of nasal irrigation and instillation of nasal sprays.
Causes of ARS4,7,8
* influenza A and B
* respiratory syncytial virus
* Streptococcus pneumoniae
* Haemophilus influenzae
* Moraxella catarrhalis
* Staphylococcus aureus
* Other Streptococcus species
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14. Melvin TA, Lane AP, Nguyen MT, Lin SY. Allergic rhinitis patients with recurrent acute sinusitis have increased sinonasal epithelial cell TLR9 expression. Otolaryngol Head Neck Surg. 2010;142(5):659–664.
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