Rhinosinusitis
GENERAL PRINCIPLES
• Acute rhinosinusitis is most frequently caused by upper respiratory viruses. Bacterial pathogens, such as S. pneumoniae, H. influenzae, Moraxella catarrhalis, and anaerobes, are involved in 10 days.
In immunosuppressed patients, fungal causes (i.e., Mucor, Rhizopus, and Aspergillus species) should be considered.• Chronic rhinosinusitis may be caused by any of the etiologic agents responsible for acute sinusitis, as well as S. aureus, Corynebacterium diphtheriae, and many anaerobes (e.g., Prevotella spp., Veillonella spp.). Possible contributing factors include asthma, nasal polyps, allergies, or immunodeficiency.
DIAGNOSIS
Clinical Presentation
• Acute rhinosinusitis presents with purulent nasal discharge, nasal obstruction, facial or dental pain, and sinus tenderness with or without fever, lasting 12 weeks including mucopurulent drainage, nasal obstruction, facial pain or pressure, and decreased sense of smell with documented signs of inflammation.
Diagnostic Testing
• Diagnosis requires objective evidence of mucosal disease, usually with rhinoscopy and nasal endoscopy. If radiological imaging is done, limited sinus CT should be used. Plain films are not recommended.
• When performed, sinus cultures should be obtained by nasal endoscopy or sinus puncture. Nasal swabs are not helpful.
TREATMENT
• The goals of medical therapy for acute and chronic rhinosinusitis are to control infection, reduce tissue edema, facilitate drainage, maintain patency of the sinus ostia, and break the pathologic cycle that leads to chronic sinusitis.
• Acute rhinosinusitis
î Symptomatic treatment is the mainstay of therapy, including oral decongestants and analgesics with or without a short course of topical decongestant or intranasal glucocorticoid.17
î Empiric antibiotic therapy is indicated only for severe persistent symptoms (≥10 days) or failure of symptomatic therapy. First-line therapy should consist of a 5- to 7-day course of amoxicillin- clavulanate 875 mg/125 mg PO q12h. Doxycycline or a respiratory fluoroquinolone (e.g., moxifloxacin, levofloxacin) may be used as alternative therapy in case of β-lactam allergy or primary treatment failure. TMP-SMX and macrolides are not recommended for empiric therapy due to high rates of resistance.
• Chronic rhinosinusitis. Treatment usually includes topical and/or systemic glucocorticoids; the role of antimicrobial agents is unclear. If antibiotics are prescribed, amoxicillin-clavulanate is considered first line; clindamycin can be used in the setting of penicillin allergy. Some chronic cases may require endoscopic surgery.