Treatment of Acute Sinusitis/Rhinosinusitis

Kat Rodgers, PA-C

Acute Viral Rhinosinusitis:

The vast majority of cases of acute rhinosinusitis (ARS) is due to viral infection. Acute viral rhinosinusitis (AVRS) begins with viral inoculation via direct contact with the conjunctiva or nasal mucosa. The most common viruses that cause AVRS are rhinovirus, influenza virus, and parainfluenza virus. 

Risk factors for ARS include older age, smoking, air travel, exposure to changes in atmospheric pressure (eg, deep sea diving), swimming, asthma and allergies, dental disease, and also immunodeficiency.

Symptoms of acute rhinosinusitis (ARS) include nasal congestion and obstruction, purulent nasal discharge, maxillary tooth discomfort, and facial pain or pressure that is worse or localized to the sinuses and also when bending forward. Symptoms normally last 7-10 days or are vastly improving by day 10. Other symptoms include fever (usually only within the first 24-48 hours), fatigue, cough, hyposmia or anosmia, ear pressure or fullness, headache, and halitosis, also ear pain/fullness.

Symptom Management

Treatment includes supportive measures only. See chart below.

Acute Bacterial Sinusitis:

Acute bacterial sinusitis differs from viral in longevity and symptom duration as well as specific risk factors for the population. Most common pathogens for bacterial cause include Streptococcus Pneumoniae, Haemophilus Influnzae and also Moraxella Catarrhalis. Bacterial cause of sinusitis is rare and only accounts for 0.5-2% of cases. Patients with ABRS tend to have symptoms that last longer (>10 days). A specific difference includes a “biphasic pattern illness” which is also described as worsening symptoms after an initial period of improvement. The complexity and medical history of the patient should also be taken into consideration with prolonged symptoms, and broader coverage should be considered. Some examples also include:

• Living in regions with rates of penicillin-nonsusceptible Strep pneumo exceed 10%
• Age > 65
• Antibiotic use in previous month
• Immunocompromised
• Multiple Comorbidities (DM, cardiac, hepatic, also renal disease)
• Severe infections (temp > 102F) 

Steroids indicated for Sinusitis?

Systemic glucocorticoids NOT INDICATED. Likewise, systemic glucocorticoids in the treatment of acute bacterial rhinosinusitis should be avoided. Clinical studies show that the benefits are very small and do not outweigh the risks/ side effects of oral steroids. 

Complications of Acute Bacterial Rhinosinusitis

Complications of bacterial sinusitis include (but are not limited to) preseptal (periorbital) or orbital cellulitis, subperiosteal abscess, meningitis, osteomyelitis of the sinus bones, Intracranial abscess, Septic cavernous sinus thrombosis. Some examples of signs/symptoms that are alarming and require immediate attention/referral include:

• Severe and persistent headache
• Periorbital edema, inflammation, or also erythema 
• Vision changes (double vision or impaired vision)
• Abnormal extraocular movements
• Proptosis
• Pain with eye movement
• Cranial nerve palsies
• Altered mental status
• Neck stiffness or other meningeal signs
• Papilledema or other sign of increased intracranial pressure

Imaging and Urgent Referral 

Imaging is not indicated in patients with clinically diagnosed uncomplicated rhinosinusitis unless you suspect complications. However, imaging is indicated in the evaluation of patients with signs or symptoms suggesting spread of infection beyond the paranasal sinuses and nasal cavity. 

Urgent early referral to an emergency department is also essential for patients with symptoms that are concerning for complicated acute bacterial rhinosinusitis or have evidence of complications on outpatient imaging. 

Imaging recommendation in the emergency department at this time would be a CT maxillofacial w/ contrast or in more severe cases MRI with and without contrast. It is also suggested that symptoms are present for a minimum of 1 month. This metric is also important when considering quality quidelines and reimbursement.

Antibiotics

Outpatient antibiotic regimens for uncomplicated acute bacterial sinusitis are shown below:

In general, oral antibiotics should not be given as an initial treatment option within the first 7 days of symptoms. This is because most sinusitis cases should be presumed to be viral in origin. Likewise, when bacterial infection is presumed after 7 days of symptoms, treatment duration should last for a minimum of 7-10 days.

Not responding to initial regimen of antibiotics

If someone returns with bounce back symptoms of sinusitis after initially feeling better after their first 7-day course of treatment, it is reasonable to broaden their antibiotic coverage and extend the duration of said antibiotic. For example, if someone was given 7 days of amoxicillin it is reasonable to start them on Augmentin x 10 days. An important caveat is that when deciding to broaden coverage and expand duration of treatment, that you are not concerned for a complication of sinusitis at that time. Have low suspicion for the risk factors listed above for patients who have a particularly complex medical history or are susceptible to poor outcomes, as well as those with alarming red flag symptoms to suggest spread of infection beyond the sinuses and nasal passage. Likewise, those patients need urgent referral with STAT imaging and specialty evaluation.

When to refer to otolaryngology (ENT) 

There are 3 general reasons for specialty follow up: 

When symptoms become chronic (>4 weeks) or when someone has persistent, non-concerning symptoms after antibiotic use it is appropriate to refer them to otolaryngology for further evaluation and symptom management as well as CT imaging to rule out anatomical abnormalities causing their prolonged symptoms.

Second, when there has been recurrent acute sinusitis in a short duration of time that has required multiple regimens of antibiotics it is also reasonable to have on follow up with ENT.

Lastly, if there were complications of acute bacterial sinusitis that required ER visit or inpatient hospital stay it is imperative that patients follow up as an outpatient is with ENT. 

Severe sinusitis can cause osteomyelitis of the sinuses, extension into the cranium, and and also cause meningitis is extreme cases.

Summary 

In general, most cases of sinusitis are uncomplicated, viral and only require supportive therapy. When a bacterial cause is suspected it is important to choose the right antibiotic regimen. There is no indication for Systemic glucocorticoids in the management of acute rhinosinusitis. Complicated bacterial sinusitis also requires urgent management. Likewise, these patients should be seen in the ER for imaging and management. If your patient has chronic sinusitis (>4 weeks) without concern for a bacterial component and after trialing antibiotics, or if they are getting acute sinusitis repetitively throughout the year it is appropriate to send them to ENT for further management. After a severe complication of sinusitis, it is also important to have the patient follow up and follow with ENT for resolution of symptoms. 

References

Hwang , P. H., & Patel, Z. M. (2021, July 27). Acute Sinusitis and Rhinosinusitis in Adults: Clinical Manifestations and Diagnosis. Uptodate. Retrieved January 31, 2022, from https://www.uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults-clinical-manifestations-and-diagnosis?search=sinusitis&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=3 

Hwang , P. H., & Patel, Z. M. (2021, July 27). Acute Sinusitis and Rhinosinusitis in Adults: Clinical Manifestations and Diagnosis. Uptodate. Retrieved January 31, 2022, from https://www.uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults-clinical-manifestations-anddiagnosis?search=sinusitis&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=3 

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Sinusitis can be painful and a common cause for medical treatment. This article describes the right way to treat it!