Download acute rhinosinusitis

ACUTE RHINOSINUSITIS
HUNTER A. HOOVER, M.D.
CHARLOTTE EYE EAR NOSE AND THROAT ASSOCIATES, P.A.
Viral Rhinosinusitis  the common cold
1. History
(a) Duration of symptoms
 improving (but not necessarily resolved) after 7-10 days
(b) Pattern of symptoms
 initially, sore throat (with fever and myalgia)
 then, nasal symptoms (may have purulence for a few days)
 finally, cough (which usually lasts weeks)
2. Treatment
(a) Antihistamines
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 first generation antihistamines help
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 because of their anticholinergic activity
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 alkylamines produce the least sedation and most anticholinergic activity
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 ex: chlorpheniramine and brompheniramine
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 majority of OTC meds contain chlorpheniramine
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   ex: Chlor-Trimeton, Comtrex, Contac, Pediacare
 antihistamines in tannate form are dosed BID, even in suspension form
 ex. chlorpheniramine tannate (with phenylephrine tannate) in Rynatan susp.
(b) Methscopolamine nitrate
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 antisecretory agent, so causes drying of secretions
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 including saliva
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 does not significantly cross blood brain barrier
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 so sedation is unlikely
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 may be combined with:
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 decongestant (ex. AlleRx-D)
 decongestant in morning and antihistamine/decongestant in evening
(AlleRx Dose Pack & AlleRx-PE Dose Pack…available in 10 & 30 day packs)
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 antihistamine (ex. AlleRx DF Dose Pack)
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 antihistamine/decongestant (ex. Dallergy)
(c) Anticholinergic spray
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 Atrovent 0.06% indicated for rhinorrhea of colds
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 in adults and children 6 years and up
(d) Oral decongestants
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 pseudoephedrine is probably superior to phenylephrine
 pseudoephedrine tannate and phenylephrine tannate are dosed BID, even in suspension

 does not seem to worsen controlled hypertension
(e) Topical decongestants

 in adults, oxymetazoline (Afrin) BID or phenylephrine (Neo-Synephrine) QID
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 in children 2-6 years old, consider prescription for tetrahydrozoline (Tyzine) QID
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or, in select cases, diluted Afrin
more effective with less side effects than oral decongestants 
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must emphasize need to limit duration of use to 5 days or less 
(f) Expectorants
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 unlikely benefit, since secretions typically not thick
(g) Antitussives
 limited benefit
(h) Combination products
 antihistamine/decongestant combinations seem to have the most benefit

 Ryna-12 is a liquid combination dosed b.i.d.
 must weigh benefit against side effects (sedation, insomnia, urinary retention, etc.)
(i) Zinc gluconate lozenges
 theoretic mechanism of action is local, not systemic
 dissolve one lozenge in mouth every 2 hours while awake beginning within 24
hours of onset of cold
 high incidence of nausea and bad taste
 conflicting studies as to effectiveness
(j) Zinc nasal swabs and spray
 marketed as Zicam cold remedy swabs and spray
 removed from market due to FDA concerns
regarding possible loss of sense of smell
(k) No antibiotics
 antibiotics have only a small chance of be beneficial
 in adults, only 1% of colds become bacterial sinusitis
 in children, only 0.5-5% of colds become bacterial sinusitis
 the small chance of preventing a bacterial infection must be weighed against
 increased incidence of developing resistant bacteria
 potential side effects of the antibiotic
 studies substantiate that patient satisfaction can be achieved without prescribing antibiotics
Acute Bacterial Rhinosinusitis
1. History
 Factors to consider:
(a) duration of symptoms
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  lasting at least 7-10 days
(b) persistency of symptoms
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  not improving after 7-10 days
(c) pattern of symptoms
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  worsening of symptoms after initial improvement (i.e “double sickening”)
(d) type of symptoms
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  persistent purulent nasal discharge 
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  facial pain/pressure
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  especially localized facial pain and/or maxillary teeth pain
 nasal obstruction 
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  fever beyond the first few days 
 Diagnostic guidelines (Otol-HNS 2007;137:S1-S31)
(a) symptoms persisting more than 10 days and including:
- purulent nasal discharge, and
- nasal obstruction, or facial pain

(b) symptoms worsening after initial improvement (i.e “double sickening”)
  even if less than 10 days
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2. Physical Exam
(a) Anterior rhinoscopy
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 pus in the nasal cavity is supportive, but not conclusive, for bacterial infection
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 purulent drainage may also be seen in oropharynx
(b) Percussion (i.e. tap tenderness)
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 not helpful, unless definitely abnormal
(c) Transillumination
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 in adults, helpful if done with proper technique and if definitely normal or abnormal
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 in children, no proven benefit
(d) Nasal endoscopy
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 helpful but requires expertise, special equipment, and patient cooperation
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3. X-Ray
(a) Plain films
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 correspond to maxillary sinus aspirate in only 70% of cases
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  findings of “air-fluid level” and “maxillary opacification” are relatively specific
for bacterial maxillary sinusitis
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 including the finding of “mucosal thickening” increases the sensitivity, but
decreases the specificity of plain films
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 the absence of all three of these x-ray findings strongly suggests against
bacterial maxillary sinusitis
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extremely poor in evaluating the ethmoid sinuses
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  a normal plain film may rule out maxillary sinusitis, but not ethmoid sinusitis
(b) CT
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“gold standard” for detecting inflammation, but not necessarily a bacterial infection
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  90% of viral infections have abnormal mucosal thickening on a sinus CT
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  30% of reportedly asymptomatic patients have abnormal findings on a sinus CT
4. Antibiotic Treatment
(a) Need for antibiotics
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 spontaneous resolution rate of clinically determined sinusitis is around 66%
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 benefits of antibiotic:
 more rapid resolution of symptoms
 50% reduction in clinical failures
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 recent position paper (Otol-HNS 2007; 137:S1-S31) endorsed watchful waiting as an
option (not recommendation) if:
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 mild illness
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 assurance of follow-up
(b) Choice of antibiotics
 first line:
 pediatric…amoxicillin 80 mg/kg/day divided BID
 take child’s weight in pounds
 double it
 add a zero
 give that dose BID
 adult…amoxicillin 500 mg three tablets BID
 second line (in order of efficacy):
 Avelox / Levaquin
 Augmentin XR and ES
 Augmentin 875
 Vantin / Omnicef / Ceftin
(c) Duration of antibiotics
 short course therapy of 5 days may be adequate for most routine cases
 as supported by “double tap studies”
 more prolonged courses may be warranted for chronic and/or recurrent cases
5. Adjunctive Treatment
(a) Topical decongestant

(b) Oral decongestant
 refer to “Viral Rhinosinusitis” section
(c) Antihistamine
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 usually not necessary because most cases of sinusitis follow a “cold”, not allergies
 if used, select a second generation one to avoid anti-cholinergic drying effects
 unlike colds where first generation antihistamines should be used
(d) Expectorant
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 for guaifenesin to be effective, need maximum dosing
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 2-6 years old……total daily dose of 600 mg
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 6-12 years old..…total daily dose of 1200 mg
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 12 years and up…total daily dose of 2400 mg
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 products that provide 2400 mg for a day
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 Robitussin (guaifenesin 100 mg/5 cc) 30 cc QID
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 Mucinex (guaifenesin 600 mg) 2 tabs BID
 generic guaifenesin tabs (400 mg) 2 tabs TID
 immediate release and least expensive
(e) Saline wash 
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 instead of 1-2 sprays, “wash” with
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 multiple squirts from OTC nasal spray container
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 lavage bottle (ex. www.neilmed.com)
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 neti pot
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 commercial canisters which “wash”
 Simply Saline (available at most drugstores)…either normal or hypertonic saline
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 ENTsol spray (available at www.entsolwash.com)...hypertonic saline
 can make hypertonic saline, by adding
 1 heaping teaspoon of Kosher or canning/pickling salt
 plus a pinch of baking soda
 into 8 ounces of distilled water
(f) Topical nasal steroid sprays
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 appear safe to use even in the presence of a bacterial infection
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 Cochrane review in 2007 supports their use
(g) Oral steroids
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 a consideration for:
 severe sinusitis with impending complication
 persisting sinusitis despite appropriate antibiotic treatment
 most physiologic to use orally only once a day in the morning
 taper is probably not necessary if steroid course is 10 days or less
Allergic Rhinitis
1. History
-distinction from viral rhinitis:
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-fever and other systemic symptoms suggest against allergy
-itching of nose and eyes are suggestive of allergy
-allergy symptoms are chronic
 often lasting longer than 7-10 days
-allergy symptoms are recurrent
 often in a predictable pattern based on change in environment
 “frequent colds” may be allergic rhinitis
-correlation with allergy testing
-results of allergy tests need to be consistent with timing of symptoms
2. Avoidance
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-if symptoms worse during pollen seasons
-keep windows closed and allow AC to filter out the pollens
-if symptoms are perennial (i.e. possible dust mite allergy)
-use pillow and mattress mite-proof encasings
-use a vacuum with HEPA filtration or special allergy bags on a weekly basis
-keep humidity less than 50%
-exterminate any cockroaches
-if symptoms worse with animal exposure
-ideally, get rid of offending pet
-more realistically, keep pet out of patient’s bedroom, and
place free-standing HEPA air cleaner in patient’s bedroom
3. Nasal steroid sprays
-most effective allergy medicine available
-multiple trials show superior efficacy to oral antihistamines, Astelin, Singulair, etc.
-especially for the symptom of congestion
-most effective if used on a daily basis
-due to delayed onset of action
-but effective even with prn use
-current studies suggest excellent long-term safety profile
-clinical trials suggest equal efficacy between all nasal steroid sprays
-compliance is the key
-patients prefer unscented sprays
-Nasonex, Nasacort, Rhinocort, Omnaris and Veramyst (lowest volume of spray)
-patients prefer low co-pay
-Flonase is generic (but is scented)
-age indications
-Nasonex , Nasacort-AQ and Veramyst: 2 years and up
-Flonase: 4 years and up
-Rhinocort Aqua and Omnaris: 6 years and up
-technique of administering may decrease incidence of epistaxis
-avoid spraying towards the septum
4. First generation oral antihistamines
-studies show patients may have psychomotor impairment
-even without subjective sedation
-anticholinergic side effects are possible
-dry mouth, blurring of vision, urinary retention, etc.
5. Second generation oral antihistamines
-no anticholinergic side effects
-so no dry mouth nor urinary retention side effects
-so no benefit for rhinorrhea of colds or vasomotor rhinitis
-no significant decongestant properties
-so more beneficial for “runners” than “blockers”
-Cetirizine (Zyrtec)
-studies suggest superior efficacy
-low-sedating (not non-sedating)
-requires warning regarding driving and use with alcohol
-generic OTC is relatively inexpensive
-Levocetirizine (Xyzal)
-clinical trials showing superior efficacy to Zyrtec are lacking
-low-sedating (not non-sedating)
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-requires warning regarding driving and use with alcohol
-Loratadine (Claritin)
-may not be as effective as other antihistamines
-generic OTC is relatively inexpensive
-Desloratadine (Clarinex)
-clinical trials showing superior efficacy to Claritin are lacking
-Fexofenadine (Allegra)
- combines effectiveness and safety
- The Medical Letter: April 30, 2001 and March 18, 2002
-available as a generic
Nasal antihistamine spray (Astelin and Astepro)
-indicated both for allergic and non-allergic rhinitis
-poor masking of the placebo may explain Astelin’s “efficacy” for non-allergic rhinitis
-bitter taste
-low sedating (not non-sedating)
-requires warning regarding driving and use with alcohol
Leukotriene receptor antagonist (Singulair)
-theoretically, should relieve congestion better than antihistamines
-however, not substantiated by clinical trials
-theoretically, combining antihistamine with leukotriene antagonist should be additive
-however, not substantiated by most clinical trials
-also indicated for asthma
-so may be a good option for patient with asthma and allergic rhinitis
Cromolyn sodium spray (Nasalcrom)
-OTC
-excellent safety profile, even in pregnancy
-frequent dosing required (t.i.d.-q.i.d.)
Immunotherapy
-subcutaneous injection of the antigens to which the patient is allergic
-begin at a low dose and gradually increase up to a long-term maintenance dose
-alters patient’s immune system
-so that their immune system no longer over-reacts to harmless environmental substances
-advantages
-addressing the underlying etiology (i.e. the immune system)
-outcome studies show better symptom control as compared to medications alone
-disadvantages
-potential for anaphylaxis
-20% of patients do not respond
-if respond, usually have to continue shots for 3 years or more
09/2010
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