Recurrent Sinusitis


Article Author:
Gyanendra Sharma


Article Editor:
Henry Taliaferro


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/18/2019 2:19:48 AM

Introduction

Sinusitis, also referred to as rhinosinusitis, is defined as the symptomatic inflammation of paranasal sinuses and nasal cavity mucosa. This inflammation can be as a result of viruses, bacteria, and allergens for discussion of acute and recurrent sinusitis. Acute recurrent sinusitis is diagnosed when patients have 4 or more episodes of rhinosinusitis per year without persistent symptoms in between. When symptoms continue to last for more than 12 weeks, with or without acute exacerbation, it is termed chronic sinusitis.[1] For the purpose of this article, we will be referring onlu to uncomplicated rhinosinusitis and not to sinus infection with orbital, central nervous system, or suppurative complications.

Etiology

Most common etiology for acute and recurrent sinusitis is viral infection. They are associated with acute viral upper respiratory infection. Similar to viral upper respiratory infections, they are self-limiting. When the mucous membrane of the nasal cavity and paranasal sinus is inflamed due to viruses, there is a predisposition to bacterial infection of the sinus cavity. Most common bacterial pathogens are Streptococcus pneumoniae, Hemophilus influenza, other Streptococcus species, Moraxella catarrhalis, or Staphylococcus aureus. Infrequently, methicillin-resistant Staphylococcus aureus (MRSA) or fungal pathogen can be the cause of chronic sinusitis.[1][2]

Epidemiology

Sinusitis is one of the most common causes for seeking medical attention. There are more than 30 million annual diagnoses in the United States. Among all antibiotics prescribed, one-fifth of them are directed for treatment of sinusitis. The direct cost of treatment of sinusitis is more than $11 billion in the United States. If other unaccounted losses of productivity are included, there is a significant impact on the healthcare cost and economy.

Pathophysiology

Pathogenesis of rhinosinusitis is as a result of dysfunction of sinus ostia (narrowing), the ciliary apparatus, and viscous sinus secretions. Viral upper respiratory infection or allergens result in mucosal edema to lead to narrowing of the sinus ostia causing direct mechanical obstruction. When there is an obstruction of the sinus ostium, there is a transient increase in pressure within the sinus cavity. As air is depleted in this close space, the pressure in the sinus becomes negative relative to atmospheric air pressure. This negative pressure possibly allows nasal bacteria into sinuses during sniffing or nose blowing. When the sinus ostium is obstructed, secretion of mucous by mucosa continues, resulting in fluid accumulation in the sinus. During viral colds other inflammation of nasal ostia and mucosal membranes, both the structure and the function of the mucociliary apparatus are impaired. The quality and characteristics of sinus secretions also determine the pathogenesis of sinusitis. Cilia can beat only in a fluid. The mucous blanket in the respiratory tract is made up of two layers. The sol phase is a thin, low-viscosity layer that surrounds the shaft of the cilia and allows the cilia to beat freely. The gel phase is a more viscous layer and rides on the sol phase. Alterations in the mucous layer, which occur in the presence of inflammatory debris, as in infected sinus, may further impair ciliary movement. Similarly, mucociliary dysfunction may occur due to frequent irrigation of the nasal cavity.[2]

History and Physical

Up to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain, pressure, and/or fullness. Nasal obstruction may be reported by patients as obstruction, congestion, blockage, or stuffiness or may be identified during the physical examination. Facial pain, pressure, or fullness may involve pain and tenderness over the maxillary, frontal bone or around the eyes. Acute, viral sinusitis should be presumed if the patient reports nasal cleat discharge with persistent symptoms without deterioration present for less than 10 days. Acute bacterial rhinosinusitis is presumed when the symptoms last more than 10 days or worsen within 2 days after initial improvement. Despite nature of viral or bacterial pathogens, most of the acute sinusitis resolve within 10 to 14 days. Sinusitis that persists beyond 12 weeks is termed chronic sinusitis and will require radiographic imaging and endoscopic evaluation.[3]

Evaluation

History and physical examination are key to making a diagnosis of acute and recurrent sinusitis. Radiological imaging, either x-rays, CT, or MRI are not recommended to make the diagnosis of acute recurrent sinusitis. CT of sinuses is recommended if symptoms persist for more than 12 weeks. Nasal endoscopy is recommended if there is suspicion of resistant bacterial infection, allergic fungal sinusitis, or nasal polyps and mass. In case of persistent or chronic sinusitis, cultures obtained from sinus aspirates or endoscopy may be needed to identify any resistant bacterial or fungal pathogen. Most frequent pathogens are Streptococcus pneumoniae, Hemophilus influenza, other Streptococcus species, Moraxella catarrhalis, or Staphylococcus aureus.

Treatment / Management

Decongestant

An oral decongestant will help reduce inflammation and secretion from the nasal, sinus, and respiratory tract mucosa thus assisting symptomatic relief. This may also assist in keeping the nasal ostia open and resulting in a reduction of sinus pressure. An oral antihistamine may be helpful if suspected sinusitis is as a result of allergic rhinitis. Oral steroids are not recommended for symptomatic relief.

Topical Intranasal Therapy

Nasal irrigation with saline is an effective symptomatic relief as a result of viral or allergic rhinosinusitis. It should be stressed that prolonged and frequent nasal irrigation of nasal cavity may alter the mucociliary apparatus to result into increase in symptoms of sinus congestion. A topical spray of fluticasone may help reduce inflammation and reduce the flaring up. Another topic spray such as oxymetazoline or phenylephrine nasal may help reducing congestion. Patients should be cautioned of rebound congestion following these decongestant sprays and limit the spray to 3 days.

Antibiotics

Only 0.5% to 2% of viral sinusitis results into bacterial sinusitis. Therefore, antibiotics therapy should be started only if the symptoms persist for more than 7 to 10 days without improvement and there are symptoms and signs of possible bacterial infection. The first-line of antibiotics is amoxicillin with or without clavulanate for 5 to 10 days. In patients who are allergic to penicillin, or in cases that second-line antibiotics are needed, the alternatives are doxycycline or respiratory fluoroquinolone (levofloxacin, moxifloxacin). Other alternative antibiotics include clindamycin with cefixime or cefpodoxime for 10 days.

Medical management of recurrent acute sinusitis is the mainstay of treatment. However, when the diagnosis of recurrent acute sinusitis has been made, furtherevaluation is indicated.

Interventions such as balloon sinuplasty are not recommended for recurrent sinusitis and should be reserved for patients with chronic sinusitis refractory to medical management.

Pearls and Other Issues

Points to remember:

  • Recurrent sinusitis is a clinical diagnosis defined by 4 or more episodes of symptoms of sinusitis per year without any symptoms in between.
  • Diagnostic imaging is not recommended for uncomplicated acute recurrent sinusitis.
  • While medical therapy has been the recommended treatment, many studies have shown that surgery for recurrent acute sinusitis has similar positive effects as is experienced in the surgical treatment of chronic rhinosinusitis.
  • The CT scan has shown variants of anatomy associated with a diagnosis of recurrent acute sinusitis. These include variant middle turbinates, such as hypertrophy and conchae bullosa, narrow sinus openings, Haller cells, and septal spurs. These lend themselves to correction with endoscopic surgical techniques.
  • With the introduction of balloon sinus dilatation, another method of treating recurrent acute sinusitis has emerged. This has much less morbidity and downtime than even endoscopic procedures, and is much less invasive.
  • Symptomatic treatment with decongestant and intranasal irrigation or corticosteroid nasal spray is the mainstay of treatment for the first ten days of symptoms.
  • Amoxicillin is the antibiotics of choice for treatment of suspected bacterial sinusitis.

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Recurrent Sinusitis - Questions

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A 30 year old female had left maxillary sinus surgery six months ago. On endoscopy, the natural ostia is wide open. A recent CT scan shows the sinus to be free of polyps. She continues to get recurrent sinus infections necessitating antibiotics. What is the probable cause?



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A 23 old has recurrent sinusitis. She is anxious to get pregnant and needs to have the recurrent sinusitis stop. She is currently irrigating her nose with a neti pot three times a day. She uses distilled warm water with added salt and soda bicarbonate. What should she do?



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A 42-year-old white female presents with severe nasal congestion, dry cough, low-grade fever and sinus congestion for the last three days. She has a history of hypothyroidism and controlled diabetes mellitus. She states that she would like to get rid of this "crud" soon so that she could go on her vacation in five days. She has had three similar episodes in the past year with no symptoms in between. What should be recommended?



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Which one of the organism is a less common bacterial cause of community-acquired sinusitis?



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Which of the following is not a common complication of acute recurrent bacterial sinusitis?



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Recurrent Sinusitis - References

References

Current Concepts in Adult Acute Rhinosinusitis., Aring AM,Chan MM,, American family physician, 2016 Jul 15     [PubMed]
Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses., Beule AG,, GMS current topics in otorhinolaryngology, head and neck surgery, 2010     [PubMed]
Clinical practice guideline (update): adult sinusitis., Rosenfeld RM,Piccirillo JF,Chandrasekhar SS,Brook I,Ashok Kumar K,Kramper M,Orlandi RR,Palmer JN,Patel ZM,Peters A,Walsh SA,Corrigan MD,, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2015 Apr     [PubMed]

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