URI Normal Course


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Acute Rhinosinusitis

  • Defined as up to 4 weeks of purulent (not clear) nasal drainage accompanied by nasal obstruction (congestion), facial pain/pressure/fullness, or both
  • Symptoms most highly predictive of acute sinusitis (viral or bacterial): purulent rhinorrhea + nasal congestion and/or facial pain/pressure

Acute viral rhinosinusitis
(viral URI)
Acute bacterial rhinosinusitis (ABS)
Recurrent acute rhinosinusitis
Acute invasive fungal rhinosinusitis
Clinical Features or Definition
Typically resolves 7-10 days but progress to bacterial sinusitis in 0.5-2%
  • Up to 75% resolve without treatment in 4 weeks
  • Most common cause is classically S. pneumoniae, H. influenzae (nontypeable), and M. catarrhalis
    • H. flu appears to have become more common and S. pneumo less common as causes of ABS in children
      Rates of beta-lactamase production in H. flu have increased in many geographic areas
  • In children typically presents as viral URI that persists >10 days without improvement, or worsening of URI symptoms after initial improvement, or severe symptoms (fever, purulent rhinorrhea) for 3-4 days
Definition
  • Acute rhinosinusitis >3 times per year
  • 2 of the cardinal signs of sinusitis
  • Normal between episodes
  • Disease of immunosuppressed or poorly controlled diabetics
  • Rapidly progressive and life-threatening intravascular tissue invasion by fungi (Mucor, Rhizopus, Aspergillus, Absidia and Basidiobolus)
Treatment (Adult)
Primarily supportive treatment indicated:
  • Acetaminophen, NSAIDs
  • Irrigation with buffered hypertonic saline
  • Intranasal steroids
  • Topical, oral decongestant
  • Intranasal ipratroprium
  • 1st generation (drying) antihistamines

Approach to acute rhinosinusitis (Kaliner)
  • Hydration (6-8 glasses of water per day)
  • Oxymetazoline BID x 3-7 days
  • Nasal saline sinus rinse BID
  • Nasal steroid 2 sprays each nostril BID
  • Analgesics PRN
  • Antibiotics if symptoms persist >7-10 days
  • Supportive treatment (as for viral URI)
  • Watchful waiting up to 1 week if mild pain and temp <101 F

  • Antibiotics
    • 1st line: Amoxicillin 500 mg PO TID x 10-14 days
    • PCN allergic: TMP-SMX or azithromycin
    • Treatment failure (symptoms fail to improve in 7 days or worsen): Levofloxacin 500 mg PO QD, high dose amox/clav 4g/250 mg/day
      • Consider sinus CT to confirm diagnosis

  • Relapse within 2 weeks:
    • If had improved significantly on original antibiotics: repeat same antibiotic with longer course
    • If minimal improvement: repeat course with different antibiotic
Same as acute bacterial rhinosinusitis
Emergent ENT referral, surgical debridement, systemic anti-fungal therapy
Treatment (Pediatric)
  • Supportive treatment (as above) though less evidence for their effectiveness in children
  • Cough/cold medications typically not recommended for children <6 years
  • Supportive treatment (as for viral URI) though less evidence for their effectiveness in children
  • For persistent acute ABS (nasal discharge of any quality, cough, or both, persisting for >10 days without improvement) may observe for 3 additional days before starting antibiotics
  • For double sickening or severe symptoms (fever39 C, purulent nasal discharge for
    3 days) may start antibiotics

  • Antibiotics (AAP 2013)
    • Duration of treatment 10-14 days but consider continuing until symptom free + 1 week more
    • Azithro/clarithromycin and TMP-SMX are no longer recommended due to high rates of resistance among both S. pneumo and H. flu isolates
    • If uncomplicated, mild-moderate severity, no day care, no antibiotics in past 30 days:
      • Amox 45 mg/Kg/d div PO BID
      • Amox 90 mg/Kg/d div PO BID (max 4 g/d) in communities with high prevalence of resistant S. pneumo
    • If uncomplicated, moderate/severe severity, attend daycare, or taken antibiotics in past 90 days:
      • Amox/clav 80-90 mg/Kg/d of amox component and 6.4 mg/Kg/d of clav div PO BID (max amox 4 g/d)
      • Cefdinir 14 mg/Kg/d PO QD or div BID
      • Cefuroxime 30 mg/Kg/d PO div BID
      • Cefpodoxime 10 mg/Kg/d PO div BID
      • Cefixime 8 mg/Kg/d
      • If unable to tolerate PO: Ceftriaxone 50 mg/Kg IM q24 then switch to PO when not vomiting
    • PCN allergy:
      • Cephalosporin likely safe (but consider allergist)
      • For the rare patient with mod/severe ABS, severe allergy to PCNs and <2 yo:
        • Levofloxacin liquid 16 mg/Kg/d PO div BID
        • Clindamycin 30-40 mg/Kg/d PO div TID + cefixime

  • If treatment with amox/clav fails >72 hours, switch to levofloxacin (covers S. pneumo, H. flu, M. cat) or a combination of clindamycin (for S. pneumo) + cefixime (for H. flu and M. cat) or linezolid 20-30 mg/Kg/d div BID-TID (for S. pneumo) + cefixime may be offered (see below)
Same as acute bacterial rhinosinusitis
Emergent ENT referral, surgical debridement, systemic anti-fungal therapy
Worsening ABS tx.png

Chronic Rhinosinusitis



References