Download Sinusitis - Lisa Helmer

Running head: SINUSITIS
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Sinusitis
Lisa Helmer
State University of New York Institute of Technology
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Sinusitis
Literature Review
State of Science. You will see this condition called sinusitis, you will see it called
rhinosinusitis. The two terms are used interchangeable throughout literature. According to the
American Academy of Otolaryngology, the term rhinosinusitis is preferred because sinusitis
almost always involves the nasal cavity (Mahoney & Rosenfeld, 2007). To avoid confusion, the
term sinusitis will be used throughout this paper.
Although sinusitis might appear benign, the impact on quality of life due to symptoms
leads many patients to seek medical care (De Moor, Reardon, McLaughlin, Maiese, &
Navaratnam, 2012). Since it is one of the most common conditions encountered by the primary
care provider, it would behoove the provider to be knowledgeable on the disease process and the
current recommendations and guidelines.
Subtypes. Prior classification divided patients with sinusitis into three categories: acute,
sub-acute, and chronic. One group of researchers believed that this type of classification did not
take into account the mechanisms that may be underlying the condition - such as the emerging
role of fungi. Also in those with chronic sinusitis it did not differentiate the nature of the
inflammation, as the outcome was different for those with or without polyps. The conclusion of
the research was that sinusitis should be divided into four categories: acute (bacterial), chronic
without polyps, chronic with polyps, and allergic fungal sinusitis. The aim of this categorization
was to guide future guidelines and research (Gendy, Walsh, McConn-Walsh, & Costello, 2007).
Guidelines. To improve the diagnosis and treatment of patients with sinusitis and reduce
the inappropriate use of antibiotics, clinical guidelines have been developed. During the past 10
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years, several expert panels from authoritative bodies have published evidence-based guidelines
for the diagnosis and management of sinusitis and its sub-types (Meltzer & Hamilos, 2011).
The most recent guidelines, published in April of 2012 edition of the journal, Clinical
Infectious Diseases again review the common problem of sinusitis and antibiotic resistance.
Antibiotics should only be used when symptoms of a sinus infection last for 10 days or more and
are not improving or when symptoms are severe, including a fever of 102 degrees or higher,
nasal discharge, and facial pain for three to four days in a row. Whether bacterial of viral, it is
strongly recommended to avoid decongestants and antihistamines as they can worsen symptoms.
If antibiotics are chosen due to the clinical presentation, a combination of amoxicillin and
clavulanate, which overcome antibiotic resistance, should be prescribed. Avoid amoxicillin
alone as well as azythromycin, clarithromycin and trimethoprim-sulfamethoxazole.
Credible Authorities. The experts in the fields of infectious diseases, pediatrics,
otolaryngology, allergy, and microbiology are the credible authorities. A group of highly
respected opinion leaders in these fields worked together and developed guidelines by the
Clinical Advisory Committee on Pediatric and Adult Sinusitis (CAC) ("New guidelines, 2011").
It seems logical to have these experts provide guidelines to general practitioners. After all, it is
the specialists in these fields that are called upon when symptomology baffles the primary care
provider.
Similarities and Differences. There have been numerous articles written and evidencebased guidelines put forth for the diagnosis and management of sinusitis - including its subtypes.
The literature reviewed recommend that the diagnosis and treatment of sinusitis should be based
on clinical criteria alone without the confirmation of imaging or other laboratory testing
("Guidelines," 2008). This appears to be agreed upon and adhered to; however, the prescribing
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of antibiotics among providers varies. Literature is emphasizing the problems with this and the
problems associated with prescribing unnecessary antibiotics.
Gap in Literature. While conducting this literature review, there was not a shortage of
information found. It is evident that due to the high prevalence and incidence of this condition
that information and recommendations will continue, in an attempt to maintain a standard of
care.
Description of Sinusitis
Pathophysiology. In order to understand sinusitis it is important to understand the
anatomy and physiology of the paranasal sinuses. The majority of the sinuses drain mucous
secretions (and obtain aeration) through a common pathway, called the osteomeatal complex,
into the nasal cavity (Hawthorne & Ahmad, 2010). Sinusitis is an inflammation of the mucous
membranes of one or more of the paranasal sinuses: frontal, sphenoid, posterior, ethmoid,
anterior ethmoid, and maxillary (Dunphy, Winland-Brown, Porter, & Thomas, 2011, p. 303).
The mucus that is produced by the mucosa of the sinuses traps particulate matter and bacteria.
The increased mucus production adds to the inadequate clearance of sinuses with subsequent
stasis, increased bacterial load, exacerbating inflammation of the mucosa with further increased
mucus production. Increased stasis of mucus secretions leads to reduced aeration and function of
the cilia with even further reduction of mucus clearance resulting in a vicious cycle leading to
acute sinusitis (Hawthorne & Ahmad, 2010, p. 209).
Important information for the clinician treating children is that the frontal sinuses begin
their development at 7 years old with complete development at adolescence. If sinusitis is
suspected in children, the maxillary and anterior ethmoid sinuses are most frequently involved
because they are present at birth (Burns, Dunn, Brady, Barber-Starr, & Blosser, 2009).
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As with any other infection sinusitis can be the cause of delirium in a frail older adult
(Weber & Kelley, 2003). Care must be taken not to overlook the obvious.
Etiology. It is difficult to differentiate on clinical presentation whether or not the
infection is bacterial or viral. Most cases of sinusitis are due to uncomplicated viral, upper
respiratory tract infections (Centers for Disease Control and Prevention [CDC], 2012). With that
being said, viral sinusitis is the main predisposing factor for acute bacterial sinusitis. The most
common bacterial pathogens isolated in acute sinusitis are Streptococcus pneumoniae (40% of all
cases - especially during the summer and fall), Haemophilus influenzae (30% of all cases - in the
winter and spring). Moraxella (Branhamella) catarrhalis is another pathogen, not so common in
adults, but rather children (Dunphy et al., 2011, p. 304).
Incidence
Acute bacterial sinusitis (ABRS) is one of the most commonly diagnosed diseases
worldwide (Benninger, 2007, p. 873). The prevalence and incidence has increased and it is now
estimated that 31 million patients in the USA have been affected by the condition (Gendy,
Walsh, McConn-Walsh, & Costello, 2007). This condition can negatively affect the individuals
quality of life and impair activities of daily living. Sinusitis affects people of all ages. It affects
males and females equally, with no specific ethnic predisposition (Dunphy et al., 2011, p. 304).
Screening and Risk Factors
There is no screening for sinusitis. Sinusitis usually follows an acute respiratory
infection. There are some factors that increase a person's risk. These include: nasal passage
abnormalities (deviated septum or polyps); aspirin sensitivity that causes respiratory symptoms;
certain medical conditions such as cystic fibrosis or chronic obstructive pulmonary disease; an
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immune system disorder such as HIV or cystic fibrosis; asthma; and regular exposure to
pollutants such as cigarette smoke ("Chronic sinusitis," n.d.).
Clinical Findings
History. Collection of data from the patient is very important. Discussing the symptoms
in regards to the character, onset, location, duration, severity, pattern, and associated factors will
help in diagnosing. Patients usually report a gradual onset of symptoms, which includes pain
and pressure over the affected sinuses. As it progresses, the pain increases to a throbbing.
Depending upon the sinus involved, the patient will have pain over the cheeks and upper teeth
(maxillary); pain over the eyebrows (frontal); and pain over or behind the eyes (ethmoid).
Typically, the patient has had upper respiratory infection symptoms. Complaints of nasal
congestion, runny nose, pressure, eye pain, malaise, and fatigue may be present. This is
accompanied by yellow-green nasal discharge, voice nasality, anosmia, post-nasal drip, popping
of their ears, excessive tearing, and a headache that is worse in the morning or when bending
forward. They sometimes report a nonproductive cough and disturbed sleep (Dunphy et al.,
2011).
Physical. On inspection, purulent nasal secretions are present. There is tenderness
elicited upon palpation and percussion of the frontal and maxillary sinuses with possible crepitus.
Teeth and gums are tender. Nasal mucosa is viewed to be red and swollen.
Differential Diagnosis
Allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, mechanical nasal airway
obstruction, and chronic conditions such as sarcoidosis or Wegener's granulomatosis may all
present with nasal congestion or pain could be confused with a diagnosis of sinusitis. However,
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if these cases are uncomplicated by sinusitis, no signs of sinus inflammation will be detected
upon physical exam (Dunphy et al., 2011, p. 306)
Social and Environmental Considerations
The common cold is the most prevalent predisposing factor to sinusitis. Prevention is
key. Exposure to viruses or bacteria predispose an individual to the common cold, pneumonia
and influenza. Factors to consider are does the patient attend day care - adult or child; is the
patient institutionalized; do they smoke or are they around second-hand smoke? Do they have
allergies and do they work with the provider to manage their allergies? It should be investigated
whether or not they have recently relocated. Newly constructed buildings in which new
carpeting, paint or cabinetry made of fiberboard is present can elicit and allergic response. Are
they familiar with hand hygiene? Is a humidifier utilized if the air in the home is dry ("Mayo
clinic," 2012). Encourage patients to receive the influenza vaccine. The pneumococcal vaccine
should be encouraged as well if criteria is met.
Testing
As stated above, the diagnosis and treatment of sinusitis should be based on clinical
criteria alone without the confirmation of imaging or other laboratory testing. Additional testing
such as X-rays and CT scan may confirm inflammation, however would not determine if it is due
to a viral or bacterial infection. To discuss further testing for the sake of mentioning are:
1. Sinus X-rays and CT scan - show air-fluid level and anatomic obstruction patterns
2. Antral puncture and lavage - provides culture material to identify infectious
organism; also a therapeutic modality to clear sinus of bacteria, fluid, and
inflammatory cells
3. Nasal and sinus endoscopy - view of sinuses (Nettina, 2010)
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4. Complete blood count - to detect leukocyte elevation
5. Stains or cultures of nasal and throat secretions do not correlate with the causative
agents
6. Allergic skin testing - if allergies are suspected (Dunphy et al., 2011)
Management and Treatment Guidelines
Goal. The goal of treatment is to control infection, shrink the nasal mucosa, and to
relieve the pain. Primary care providers tend to think of sinusitis as an acute bacterial infection,
for which they prescribe an antibiotic in 85% to 98% of cases. According to data from the
National Ambulatory Medical Care Survey, sinusitis is the fifth most common diagnosis for
which an antibiotic is prescribed. However, sinusitis is frequently caused by viral infection and
will resolve in most patients without antibiotic treatment (Hickner et al., 2001).
So why do providers continue to order antibiotics so freely? Some providers say that
they practice aggressively to protect themselves from lawsuits. One reason that providers are
less likely to admit, is that it's hard to kick bad/old habits. Researchers say that providers often
embrace evidence that reinforces their practice style while ignoring evidence that conflicts with
it ("When To Say," 2012). Antibiotics used for viral infections increases the risk of antibiotic
resistance, a public health threat as declared by the Institute of Medicine, the Centers for Disease
Control and Prevention (CDC), and the World Health Organization (WHO). And yet,
unnecessary prescribing continues despite this fact (Grover et al., 2012).
Surgical management carries its own risks, however, treatment of chronic sinusitis may
require surgical intervention if medical treatment alone is not sufficient to control the symptoms.
Surgeries many include polyp removal, correction of a deviated septum or incising and drainage
of the sinuses (Smeltzer & Bare, 1996). One of the main symptoms of patients with chronic
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sinusitis is the impaired sense of smell. The loss of olfaction can reduce quality of life and could
interfere with a person's professional capacities - such as a cook or firefighter. A study was
completed on patients who underwent endoscopic sinus surgery and if improvement was noted
with their sense of smell. The research did show improvement and therefore promoted the
surgery, but the length of time that a large majority of the individuals were studied was within a
year after the surgery - leaving questions on long-term results (Briner, Jones, & Simmen, 2012).
In some patients, relief from chronic sinusitis is obtained by moving to a dry climate.
Non-pharmacological. Sinusitis usually stems from a viral infection, not a bacterial one.
Antibiotic therapy is of no benefit for patients with viral infection (Steurer et al., 2009). With
this being said, providers should not rush to prescribe antibiotics. So what can be done to help
the patient who is suffering with symptoms of sinusitis? Education regarding why you will not
be prescribing an antibiotic will be first and foremost. The patient is, no doubt, in the office to
receive a pill to relieve their symptoms that is affecting their activities of daily living. After this
explanation is provided, there are some things that they can try at home to assist with their
symptoms. According to Consumer Reports and PubMed Health, ("Is It Allergies," 2012)
("Sinusitis," 2011), these include:

Rest - this is important as the body is fighting the virus.

Drinking plenty of fluids - can assist with loosening up phlegm and thin nasal
secretions.

Apply a warm, moist washcloth to face several times a day.

Humidity - warm moist air from a bath, shower, or boiling water on stove
(inhaling the steam) can help loosen phlegm and soothe sore throat.

Use a humidifier.
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
Use a Neti pot to flush the sinuses.

Use nasal saline spray several times per day.

Gargling - dissolve half a teaspoon of salt in a glass of warm water to help relieve
painful swelling in throat.
The saline nasal irrigation is an effective management strategy for many sinonasal
conditions. This adjunctive therapy was first described in medical literature in the early 20th
century. The exact mechanism of action is unknown, but one school of thought is that it
improves nasal mucosa function through several physiologic effects, including direct cleansing,
removal of inflammatory mediators, and improved mucociliary function (Rabago & Zgierska,
2009, p. 1117).
Pharmacological. The patient presents with persistent symptoms lasting for 10 days or
more without evidence of clinical improvement. It is time to treat for acute bacterial sinusitis.
But what do you prescribe? The new guidelines published by the Infectious Diseases Society of
America (IDSA) recommend treatment with amoxicillin-clavulanate instead of amoxicillin
alone. This recommendation was based on the increasing prevalence of antibiotic resistance.
The clavulanate inhibits beta-lacramase (the bacterial enzyme that is responsible for breaking
down the antibiotic. When you inhibit this enzyme, amoxicillin is protected. Adults should
receive a course of 5 to 7 days, while children should be treated for 10 to 14 days. (Rausch,
2012).
For adults with a penicillin allergy, doxycycline or a respiratory fluoroquiniolone such as
levofloxacin may be used. For children with a hypersensitivity to penicillin, levofloxacin is
recommended or a third generation of cephalosporin may be used (Rausch, 2012).
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The new guidelines do not recommend routine use of some commonly prescribed
antibiotics used for acute bacterial sinusitis. Some of these medications include azithromycin,
clarithromycin and timethroprim-sulfamethoxazole. Wide use of these medication is not
recommended due to the increasing prevalence of drug resistance (Rausch, 2012).
In addition to the prescribed antibiotic, over-the-counter medications such as
acetaminophen and/or ibuprofen may be used for fever/aches/pains. Over-the counter spray
nasal decongestants may also be used, but used cautiously - they may help at first, but using
them for more than 3 to 5 days can actually worsen nasal congestion.
Complications
Acute sinusitis can cause complications in patients with asthma or flare-up a long-term
problem as chronic sinusitis. Delayed diagnosis of sinusitis with failure to recognize and
manage complications can be devastating for patients, potentially resulting in blindness or even
death (Hawthorne & Ahmad, 2010). Depending upon the anatomic location of the sinus
involved, the infection could extend to areas outside of the parasinus region. If the infection
spreads to the orbital contents and eyelids, orbital cellulitis can occur. This situation would
require immediate attention. Some signs that may suggest orbital cellulitis include lid edema,
edema of ocular conjunctiva, drooping eyelid, limitation of extraocular motion, and vision loss.
Osteomyelitis may spread by direct extension or through blood vessels. The frontal bone is
commonly affected. There could also be some central nervous system complications including
meningitis, subdural and epidural purulent drainage, brain abscess, and cavernous sinus
thrombosis (Nettina, 2010).
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Follow-up and Referral
Once diagnosis and treatment has been determined, patients will need to reevaluated for
symptomatic improvement in 48 to 72 hours, and a return visit should be scheduled for 10 to 14
days after initial assessment. If improvement is not noted, their sinusitis is allergic or
immunologic, refractory to antibiotic therapy, recurrent, associated with unusual opportunistic
infections, or when the infection is adversely affecting their quality of life, they need to be
referred to a specialist (Dunphy et al., 2011).
Counseling and Education
Informed patients are better able to achieve healthy outcomes as a result of improved
communication and the development of trust with their primary care provider. Information to be
shared with the patient who has been diagnosed with sinusitis may include: take prescribed and
over-the-counter medications as indicated, avoid swimming and diving during the infection as
this may cause contaminated water to be forced into a sinus, avoid cigarette smoke, advise the
patient with asthma that sinusitis has been associated with exacerbation of asthma symptoms stay alert for increased wheezing, chest tightness, or cough.
In addition to the education provided regarding sinusitis, it is also a good time to educate
the patient on tips to reduce antibiotic use - especially if antibiotics are not being prescribed
during the visit. Tips to share include: inform patients that antibiotic use increases the risk of an
antibiotic-resistant infection, recommend specific symptomatic therapy, spend time answering
questions and offer a contingency plan if symptoms worsen, and provide patient education
materials on antibiotic resistance ("Center for Disease Control and Prevention," 2012).
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Consultation and Referral
Although complications are relatively uncommon, it is necessary for the provider to
understand that there have been cases of more serious pathology. Any unilateral sign or
symptoms should be viewed with concern and early imaging employed to verify the diagnosis is
correct. Providers must have a high index of clinical suspicion and promptly refer cases
refractory to therapy or anyone who may be developing complications of sinusitis (Hawthorne &
Ahmad, 2010).
Conclusion
Patients with symptoms of acute sinusitis present to a wide range of providers. Most
acute sinusitis is caused by viruses, do not require antibiotics and resolve spontaneously. And
yet, unnecessary prescribing of antibiotics continues. It is important for all providers to be
knowledgeable of the most current guidelines. Knowledge is power - not just for the provider,
but also for the patient. Educate the patient on the disease process, the treatments, and why
antibiotics are not always recommended.
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Test Questions
1. The recommended way to diagnosis sinusitis is by
a. sinus x-rays
b. clinical presentation
c. CT scan
d. nasal scrapping
2. Clinical presentation of someone with sinusitis includes all of the following except:
a. nasal congestion, post nasal drip, yellow or green nasal discharge
b. pain worse in am
c. pain is less and they feel better when they bend over at the waist
d. dental pain
3. The sinuses that are most frequently involved in children because they are present at
birth are:
a. maxillary
b. anterior ethmoid
c. frontal
d. both a & b
e. all are present and functioning at birth
4. First-line antibiotic therapy for sinusitis is:
a. Amoxillin-clavulanate
b. Levaquin
c. Zpack
d. Tetracycline
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5. Orbital cellulitis can occur when a sinus infection spreads to orbital contents and
eyelids. Signs of orbital cellulitis include:
a. lid edema
b. edema of ocular conjunctiva
c. drooping eyelid
d. limitation of extraocular motion
e. vision loss
f. all of the above
g. a & c only
6. Some home treatments for the patient to try at home include all of the following
EXCEPT:
a. humidifier
b. drinking plenty of fluids
c. nasal decongestant for 7 to 10 days
d. use of a neti pot
7. Dropping eyelids and limited extraoccular movements are almost always signs of
sinusitis?
True
/
False
8. Research claims that the majority of sinus infections are viral and will resolve
spontaneously.
True
/
False
9. Any unilateral sign or symptom should be viewed with concern and early imaging
employed to varify diagnosis.
True /
False
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10. When an infection is present, nasal mucosa will be
a. red
b. swollen
c. pale in color
d. both a &b
e. only c
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