Acute RhinosinusitisAutors:Jana Kraķe MF3, 8.grupaMentors: Gints Tomiņš

Definition1)“Rhinitis” is the inflammation of the nasal mucosa. It can be defined as symptoms of nasal irritation, sneezing, rhinorrhoea and nasal blockage lasting for at least 1 h a day on most days. The term “sinusitis” refers to inflammation of the mucosa of the paranasal sinuses, regardless of the cause.

2)Acute rhinosinusitis is an inflammation of the paranasal sinuses and the nasal cavity lasting no longer than 4 weeks. It can range from acute viral rhinitis (the common cold) to acute bacterial rhinosinusitis.

Although sinusitis is the term commonly used for any inflammation or infection of sinuses, this term has largely been replaced by rhinosinusitis, because the nose is almost always involved with the infection or inflammation at the same time as the sinuses.

Classification of Rhinosinusitis

Acute - Up to four weeks

Subacute - At least four weeks but less than 12 weeks

Recurrent acute - Four or more episodes per year with complete resolution between episodes,each episode lasts at least seven days

Chronic - 12 weeks or longer

Classification of Rhinosinusitis 2

Localisation : maxillar sinus, sphenoidal sinus, ethmoidal sinus, frontal sinus

Infection: Bacterial/viral or fungal Morfology: exudative/productive Complication: orbital/intracranial

Predisposing factors for sinusitis Upper respiratory infections Anatomic variations Allergic rhinitis Nasal dryness Dental infections and procedures, trauma Barotrauma Hormone factors Immunodeficiency disease Inhalation of irritants Mechanical ventilation Nasotracheal and nasogastric tubes

CLINICAL FEATURESAcute rhinosinusitis may be accompanied by low‐grade fever, malaise, headache and possibly a cough.

Typical physical signs include bilateral nasal mucosal oedema, purulent nasal secretions and sinus tenderness, although this is not a sensitive or specific finding. Pain on palpation over the 1)frontal sinuses can indicate inflammation. 2)Maxillary sinus infection can cause toothache with tenderness over the molar region. 3)Ethmoid sinusitis maybe associated with swelling, tenderness and pain around the eyes.

EtiologyMost cases of acute rhinosinusitis are caused by viral infections associated with the common cold. Mucosal edema leads to obstruction of the sinus ostia. In addition, viral and bacterial infections impair the cilia, which transport mucus. The obstruction and slowed mucus transport cause stagnation of secretions and lowered oxygen tension within the sinuses. This environment is an excellent culture medium for viruses and bacteria.

Common causative organisms for acute rhinosinusitisViruses Rhinovirus Influenza virus Parainfluenza virusBacteria Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Anaerobic bacteria Staphylococcus aureus Streptococcus aureus Gram‐negative bacteria

Streptococcus pneumoniae

Haemophilus influenzae

Staphylococcus aureus

INVESTIGATIONS

Acute rhinosinusitis is mainly a clinical diagnosis. More than 50% of patients with sinus symptoms who visit primary care physicians are unlikely to have bacterial sinusitis. The clinical diagnosis of acute bacterial sinusitis is most appropriately made on the basis of the medical history, symptoms, and clinical examination.

Major criteria: nasal discharge, nasal blockage or congestion, facial pain or pressure

Minor criteria: headache, fever, tooth pain, cough.

100% - 2 major and 1 minor criteria / 2 or more minor criteria

Nasal cytology

Sinus puncture (maxillary or frontal sinus) remains the gold standard for obtaining sinus culture material, with many studies showing little correlation between nasal swab and sinus culture.Nasal cytology (Hansel, Wright of Gram stain) could be performed in cases of acute rhinosinusitis. Presence of neutrophils and bacteria suggests bacterial rhinosinusitis.

RadiologyRadiology has traditionally been used as an investigative tool to diagnose acute rhinosinusitis. This includes plain sinus radiographs and computed tomography (CT) scans of the paranasal sinuses.Vaters projection- we see maxillary sinusKaldvel projection-frontal sinusLateral projection- sphenoidal sinus,frontal sinus

Interesting fact- 40% of asymptomatic patients and 87% of patients with community‐acquired colds have sinus abnormalities on sinus CT scan.

TreatmentPrescribe antibiotic therapy based on benefits and risks. Benefits depend on the probability of bacterial infection and the severity of symptoms. Risks of antibiotics include allergic reaction, potential side effects, and promotion of bacterial resistance. First line antibiotics for acute bacterial rhinosinusitis are amoxicillin and trimethoprim/ sulfamethoxazole.(1000 mg 2x)The usual initial course of antibiotics should be 10-14 days. If symptoms worsen after 72 hours of initial empiric antimicrobial therapy, or they fail to improve despite 3 to 5 days of initial empiric antimicrobial therapy, it is reasonable to consider a change in medications.

Efficacy in symptom control: decongestants (especially topical decongestants: xilometazolynum, oxymetazolynum), topical anticholinergics and nasal steroids (Beclometazonum,Budezonidum,Flutikazonum -Eo, T ly,symptoms

Possible efficacy: zinc gluconate lozenges, vitamin C, Echinacea extract, saline irrigation

SURGICAL MANAGEMENT

Antral washout External frontoethmoidectomy Frontal sinus trephination Functional endoscopic sinus surgery

Complications of acute rhinosinusitis Preseptal cellulitis Orbital cellulitis Orbital abscess Osteomyelitis Subperiosteal orbital abscess Subdural empyema Epidural empyema Meningitis Brain abscess Cortical thrombophlebitis Cavernous/sagittal sinus thrombosis

Resaerch

Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial

Methods: We conducted a block-randomized, double-blind, placebo-controlled clinical trial at 54 primary care practices (68 family physicians) in the Netherlands between Dec. 30, 2008, and Apr. 28, 2011. Adult patients with clinically diagnosed acute rhinosinusitis were randomly assigned to receive either prednisolone 30 mg/d or placebo for 7 days and asked to complete a symptom diary for 14 days. The primary outcome measure was the proportion of patients with resolution of facial pain or pressure on day 7.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

Results:Of the 185 patients included in the trial (93 in the treatment group, 92 in the placebo group), 2 withdrew from the study and 9 were excluded from the primary analysis because of incomplete symptom reporting. The remaining 174 patients (88 in the treatment group, 86 in the placebo group) were included in the intention-to-treat analysis. The proportions of patients with resolution of facial pain or pressure on day 7 were 62.5% (55/88) in the prednisolone group and 55.8% (48/86) in the placebo group (absolute risk difference 6.7%, 95% confidence interval −7.9% to 21.2%). The groups were similar with regard to the decrease over time in the proportion of patients with total symptoms (combined symptoms of runny nose, postnasal discharge, nasal congestion, cough and facial pain) and health-related quality of life. Adverse events were mild and did not differ significantly between the groups

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

Prednisolone n =88 Placebo n = 86 Absolute risk difference, % (95% CI) Relative

risk(95% CI)

Facial pain or pressure 62.5 (55/88) 55.8 (48/86) 6.7 (−7.9 to 21.2) 1.12 (0.87 to 1.44)Severe facial pain or pressure 93.2 (82/88) 82.6 (71/86) 10.6 (1.0 to 20.2) 1.13 (1.01 to 1.26)Nasal congestion 57.5 (50/87) 53.5 (46/86) 4.0 (−10.8 to 18.8) 1.07 (0.82 to 1.40)Postnasal discharge 54.5 (48/88) 57.6 (49/85) −3.0 (−17.9 to 11.7) 0.95 (0.73 to 1.23)Runny nose 69.3 (61/88) 58.1 (50/86) 11.2 (−3.0 to 25.3) 1.19 (0.95 to 1.50)Cough 66.3 (57/86) 54.8 (46/84) 11.5 (−3.1 to 26.1) 1.21 (0.95 to 1.55)Total symptoms 32.9 (28/85)25.3 (21/83) 7.6 (−6.1 to 21.3) 1.30 (0.81 to 2.10)Severe total symptoms 81.2 (69/85) 78.3 (65/83) 2.9 (−9.3 to 15.0) 1.04 (0.89 to 1.21)4 of 5 total symptoms 44.7 (38/85) 39.8 (33/83) 5.0 (−10.0 to 19.9) 1.12 (0.79 to 1.60)3 of 5 total symptoms 62.4 (53/85) 57.8 (48/83) 4.5 (−10.3 to 19.3) 1.08 (0.84 to 1.38)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

Interpretation:Systemic corticosteroid monotherapy had no clinically relevant beneficial effects among patients with clinically diagnosed acute rhinosinusitis.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

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https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-B9781455746965000464?scrollTo=%23hl0000329

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600057/ http://www.med.umich.edu/1info/FHP/practiceguides/Rhino/rhino.pdf http://www.aafp.org/afp/2011/0501/p1057.html#sec-1 http://www.doctus.lv/2015/4/akuts-rinosinusits-un-ta-parvaldiba#_=_ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/