Rosen & Barkin's 5-Minute Emergency Medicine Consult (652 page)

DIAGNOSIS

• Facial–dental pain, headache, halitosis, hyposmia, cough
  
• Purulent nasal discharge and postnasal drainage
  
• Fever
  
• Frontal sinusitis:
  
  • Pain of the lower forehead
    
  • Pain worsened when lying on the back; improves when upright
    
• Maxillary sinusitis:
  
  • Malar facial pain
    
  • Maxillary dental pain
    
  • Referred ear pain
    
  • Pain worsens with head upright or bending forward and improves with reclining
    
• Ethmoid sinusitis:
  
  • Retro-orbital pain
    
  • Periorbital edema
    
• Sphenoid sinusitis (very uncommon):
  
  • Pain over the occiput or mastoid
    
  • Pain worse when lying on back or bending forward
    

• Acute viral rhinosinusitis:
  
  • Symptoms typically resolve in 7–10 days
    
• Acute bacterial rhinosinusitis needing antibiotic treatment can present in 3 different patterns:
  
  • Pattern 1: Persistent symptoms lasting >10 days without improvement
    
  • Pattern 2: Severe symptoms or:
    
    • Temperature ≥39°C and purulent nasal discharge for 3–4 days at the beginning of illness
      
  • Pattern 3: Worsening symptoms:
    
    • Return of symptoms after a 5–6- day duration of upper respiratory infection that was improving
      
• Other important history:
  
  • Symptom history and time course
    
  • Allergy history
    
  • Recent NG or NT tube placement
    
  • Immunocompromised state
    

• Vital signs, toxic/nontoxic appearance
  
• Edema of the nasal mucous membranes and turbinates
  
• Purulence in the nares or posterior pharynx
  
• Warmth, tenderness, or cellulitis over sinus
  
• Sinus tenderness on palpation
  
• Periorbital edema
  
• Failure of transillumination of maxillary sinuses:
  
  • Observed through the palate
    
• Dental exam revealing abscess or tenderness of maxillary teeth
  

• Clinical diagnosis based on history and physical exam
  
• Determine if patient fits pattern of acute bacterial rhinosinusitis that should be treated with antibiotics (see “History”)
  

Lab studies not helpful for diagnosis or management

• Imaging unnecessary in uncomplicated cases
  
• Plain-film radiography:
  
  • Normal films do not exclude bacterial cause
    
  • Waters view can be ordered, but has moderate sensitivity in diagnosing maxillary sinus abnormality and poor sensitivity in diagnosing lesions in other sinuses
    
  • Odontogenic maxillary sinusitis may be missed by dental exam and panorex films, but is apparent as periapical lucency on cone beam CT or sinus CT
    
• CT:
  
  • Preferred if imaging is necessary
    
  • Warranted in patients with complicated rhinosinusitis, severe headache, seizures, focal neurologic deficits, periorbital edema, or abnormal intraocular muscle function
    
  • IV contrast if concern for osteomyelitis or abscess
    

• Sinus aspirate culture:
  
  • Gold standard for making a microbial diagnosis but not routinely performed
    
• Culture of discharge may have benefit but remains unstudied and is not typically performed
  
• Functional endoscopic sinus surgery (FESS):
  
  • Restores physiologic sinus drainage
    

FESS is a safe and effective treatment in children

• Uncomplicated viral or allergic rhinitis
  
• Otitis media
  
• Dacryocystitis
  
• Migraine and cluster headache
  
• Dental pain
  
• Trigeminal neuralgia
  
• Temporomandibular joint disorders
  
• Giant cell arteritis/temporal arteritis
  
• Rhinitis medicamentosa (decongestants, β-blockers, antihypertensives, birth control pills)
  
• Nasal polyp, tumor, or foreign body
  
• CNS infection
  
• Granulomatous or ciliary disease
  
• Aspergillosis
  
• Rhinocerebral mucormycosis:
  
  • Rare rapidly progressive fungal infection
    
  • Occurs in diabetics and the immunocompromised
    
  • Orbital/facial pain out of proportion to exam
    
  • Lethargy, headache in a systemically ill-appearing patient
    
  • Black eschar or pale area on the palate or nasal mucosa
    

• Rhinitis of pregnancy:
  
  • Estrogen has cholinergic effect on mucosa
    
  • Worse during 3rd trimester
    
  • Resolves within 2 wk postpartum
    

TREATMENT

No special considerations

Toxic-appearing patients may require airway management and fluid resuscitation.

• Identifying rhinosinusitis needing antibiotics
  
• Counseling and reassurance to patients requesting antibiotics for mild symptoms <10 days duration
  

• Nonantibiotic therapies:
  
  • Pain control
    
  • Saline nasal irrigation may be beneficial
    
  • Oral corticosteroids as adjunctive to oral antibiotics are effective, but data limited
    
  • Intranasal steroids recommended as adjunct to antibiotics primarily in those with allergies:
    
    • Beclomethasone dipropionate: 1 spray per nostril QD/TID/BID
      
    • Dexamethasone sodium phosphate: 2 sprays per nostril BID/TID
      
  • Antihistamines recommended for patients with underlying allergy
    
  • Nasal or oral decongestants not recommended (phenylephrine, pseudoephedrine, oxymetazoline)
    
  • Expectorants may be helpful:
    
    • Guaifenesin:
      
      • Adult: 200–400 mg PO; not >2.4 g/24 h
        
      • Peds 2–5 yr: 50–100 mg PO; not >600 mg/24 h;
        
      • Peds 6–11 yr: 100–200 mg PO; not >1.2 g/24 h
        
• Antibiotics:
  
  • Amoxicillin–clavulanate: 250–500 mg PO TID or 875 mg PO BID (peds: 40 mg/kg/d, based on the amoxicillin component)
    
  • If high risk (systemic toxicity w/fever ≥39°C, attendance at daycare, age <2 or >65 yr, recent hospitalization, abx use in last month, or immunocompromised) use amoxicillin–clavulanate: 2 g PO BID (peds: 90 mg/kg/d, based on amoxicillin component)
    
  • Doxycycline: 100 mg PO BID (alternative for initial empiric therapy in adults)
    
• 2nd- and 3rd-generation oral cephalosporins no longer recommended for empiric monotherapy due to resistance among
  S. pneumoniae
  . Can use following combination:
  
  • Cefpodoxime: 200–400 mg PO BID (peds: 10 mg/kg/d PO BID) or
    
  • Cefuroxime: 250–500 mg PO BID (peds: 15 mg/kg/d PO BID) +
    
  • Clindamycin: 150–300 mg PO q6h (peds: 8–16 mg/kg/d PO split q6–8h, MRSA-suspected use 40 mg/kg/d PO split q6–8h)
    
• Macrolides (clarithromycin and azithromycin) not recommended due to high rates of resistance amongst
  S. pneumoniae
  (30%)
  
• Trimethoprim–sulfamethoxazole (TMP/SMX) not recommended due to high rates of resistance among
  S. pneumoniae
  and
  H. influenzae
  (30–40%)
  
• Type 1 penicillin allergy:
  
  • Levofloxacin: 500 mg PO per day (peds: 8 mg/kg) children under 50 kg max. dose 250 mg/d. Children over 50 kg max. dose 500 mg/d.
    
  • Moxifloxacin: 400 mg PO per day (adult)
    
• If symptoms not improved after 3–5 days of 1 antibiotic, switch to another antibiotic
  
• Recommended duration of therapy:
  
  • Acute: 10–14 days in children; 5–7 days in adults
    
  • Chronic: 3–6-wk course of antibiotics (controversial), douche, and nasal steroids
    

Supportive care

Antibiotics

FOLLOW-UP

• Evidence of spread of infection beyond the sinus cavity or toxic-appearing patients
  
• Immunocompromised/diabetic patients with extensive infection
  
• Multiple sinus or frontal sinus involvement
  
• Extremes of age
  
• Severe comorbidity
  
• ENT evaluation and aspiration if patient is severely ill, immunocompromised, or has pansinusitis and is ill-appearing
  

Most cases of uncomplicated rhinosinusitis may be managed on an outpatient basis.

• Complications of acute infection
  
• Immunocompromised patients
  
• Chronic rhinosinusitis or nasal polyps
  
• Concerns for osteomyelitis, CNS infection, or abscess
  
• Acute rhinosinusitis–aspergillosis
  

If patient has no relief with initial treatment and nonantibiotic therapies, follow up with PCP or ENT.

• Patients presenting with <10 days of mild symptoms should be treated with supportive care
  
• Patients presenting with ≥10 days of symptoms, severe symptoms at 4–5 days with fever, or worsening after initial improvement can be diagnosed with acute bacterial rhinosinusitis and should be treated with antibiotics
  
• Term rhinosinusitis preferred, since inflammation of sinuses rarely occurs without inflammation of the nasal mucosa
  

• Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis.
  Cochrane Database Syst Rev
  . 2008;(2):CD000243.
  
• Aring AM, Chan MM. Acute rhinosinusitis in adults.
  Am Fam Physician
  . 2011;83:1057–1063.
  
• Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.
  Clin Infect Dis.
  2012;54:e72–e112.
  
• DeMuri GP, Wald ER. Clinical practice. Acute bacterial sinusitis in children.
  N Engl J Med
  . 2012;367:1128–1134.
  
• Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults.
  Cochrane Database Syst Rev
  . 2012;10:CD006089.
  
• Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children.
  Cochrane Database Syst Rev
  . 2012;9:CD007909.
  
• Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis.
  Cochrane Database Syst. Rev.
  2011;(12):CD008115.