Acute and Chronic Rhinosinusitis Flashcards
In the past decade, the term rhinosinusitis has
been commonly used to describe what condition?
Inflammation of the nose and paranasal sinuses. This term
is preferred over sinusitis because sinusitis almost always
involves the nasal cavity.
According to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007), what
are the criteria for diagnosing rhinosinusitis?
Inflammation of the paranasal sinuses, with two or more of
the following:
● Nasal blockage, obstruction, congestion, or nasal dis-
charge (anterior and/or posterior)
● ± Facial pain or pressure
● ± Hyposmia or anosmia
Describe the five major classifications of
rhinosinusitis based on symptom time course.
● Acute: < 4 weeks with complete resolution
● Recurrent Acute: Four or more episodes per year lasting ≥ 7
to 10 days; complete resolution between episodes
● Subacute: 4 to 12 weeks; controversial designation
(considered as a “filler term”)
● Chronic (± NP): > 12 weeks, without complete resolution
● Acute exacerbations of CRS: Worsening from baseline
chronic symptoms, followed by return to baseline
What is one of the tools used to assess the
severity of rhinosinusitis symptoms?
● 10-cm visual analog scale: “How troublesome are your
symptoms of rhinosinusitis?”
● Range: 0 = Not troublesome, 10 = Worst thinkable
● 0 to 3 = Mild
● 3 to 7 = Moderate
● 7 to 10 = Severe
Define double worsening/sickening.
Symptoms that worsen following initial improvement
What type of acute rhinosinusitis occurs two to five times per year in the average adult, has a
symptom peak at 2 to 3 days, progressively
improves after day 5, and has symptom resolution
by day 10 to 14?
Acute viral rhinosinusitis
What are the two most common pathogens associated with acute viral rhinosinusitis?
Rhinovirus and Influenza virus
What percentage of viral rhinosinusitis is estimated
to progress to bacterial sinusitis?
0.5 to 2%
What type of acute rhinosinusitis lasts for > 10 days or manifests with worsening of symptoms after day 5?
Acute bacterial rhinosinusitis (ABRS)
In addition to the diagnostic symptoms associated
with rhinosinusitis, what secondary symptoms may
suggest ABRS?
Fever, aural fullness, cough, myalgias, or headache
What pathogens are most commonly involved in
ABRS?
● Streptococcus pneumoniae (30%)
● Haemophilus influenzae (20 to 30%)
● Moraxella catarrhalis (10 to 20%)
What workup is recommended for acute
rhinosinusitis?
● Not recommended: CT or X-ray
● CT may be considered for severe disease, immunocom-
promised patients, clinically suspicious complications,
preoperative evaluation, or evaluation of recurrent acute
rhinosinusitis.
Optional
● Anterior rhinoscopy
● Nasal endoscopy: Consider for initial workup, if disease is
refractory to empiric treatment, for unilateral disease,
when symptoms are severe or disabling
● Nasal culture: Treatment failure, complications
When should you consider a sinus puncture using
a large-bore needle through the canine fossa or inferior meatus for workup of acute rhinosinusitis?
● Clinical trials: Standard for identifying bacterial pathogens
in the maxillary sinuses
● Potentially useful if episodes are refractory to treatment
or when rapid diagnosis and identification of pathogens
are required (e.g., in an immunocompromised patient)
According to the European Position (EPOS) Paper
on Rhinosinusitis and Nasal Polyposis (2007) and supported by data in EPOS 2012, what treatment strategy should be used for mild acute rhinosinusitis with symptoms lasting < 5 days or improving after 5 days?
Symptomatic treatment
● Decongestant
● Saline irrigation
● Analgesics
Why do some guidelines on acute rhinosinusitis
recommend against using mucus color to dictate
antibiotic use?
Mucus color is driven by neutrophils, not bacteria.
If a patient has moderate to severe symptoms of
acute rhinosinusitis that persist or worsen after 5
days, what is the recommended treatment
according to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007) and
supported by data in EPOS 2012?
Initiate intranasal corticosteroids. If no improvement is seen
after 14 days → reconsider diagnosis, perform nasal endoscopy, consider an intranasal culture, and consider imaging. Also consider antibiotics, if indicated, if no improvement has occurred after 14 days.
For a patient with acute rhinosinusitis with a
temperature > 38oC or in severe pain, what
treatment is recommended?
● Intranasal corticosteroids
● Antibiotics
● May consider an oral steroid to decrease pain
● Symptomatic management (i.e., analgesia)
Note: Improvement is expected within 48 to 72 hours.
When should an antihistamine be used in the treatment of patients with acute rhinosinusitis?
Use antihistamines only in patients with a history of allergic rhinitis or allergic disease.
Although decongestants can benefit patients with
rhinosinusitis by decreasing mucosal swelling and
potentially relieving paranasal sinus outflow obstruction, there is no conclusive published evidence for their use in this disease. What is the maximum amount of time they should be used for?
5 days
The Infectious Disease Society of America’s (IDSA) 2012 Guidelines for ABRS in children and adults recommends initiating antibiotic therapy for what signs and symptoms?
● Persistent signs or symptoms of ABRS for ≥ 10 days
● Severe signs or symptoms for ≥ 3 to 4 days (temper-
ature ≥ 39oC, 102oF; purulent nasal discharge, facial pain at the beginning of illness, or other concerning findings suggestive of complicated ABRS)
● Worsening or double sickening at ≥ 3 to 4 days
In the IDSA’s algorithm, once a patient meets the
criteria to receive an antibiotic, the risk for
resistance must be assessed. What makes a patient
high risk?
● Age < 2 years or > 65 years
● Attends daycare
● Antibiotics taken within the past month
● Hospitalization within the past 5 days
● Immunocompromised status
● Other comorbidities such as asthma, cystic fibrosis, etc.
● Geographic region with high endemic rates of penicillin-
resistant Streptococcus pneumoniae (> 10%)
If a patient meets the criteria for an antibiotic
and is not considered at high risk for resistance,
what is the first-line antibiotic recommended by the IDSA?
Standard-dose augmentin for 5 to 7 days (adults)
These guidelines recommend against the use of amoxicillin
because of concern about an increasing number of patients
developing ABRS from Haemophilus influenza since the
introduction of pneumococcal conjugate vaccines as well as increasing β-lactamase production in these strains. However, previous guidelines published in the otolaryngology literature suggest amoxicillin as first line.
If a patient meets the criteria for an antibiotic
and is considered at high risk for resistance, what
is the second-line antibiotic recommended by the
IDSA?
● High-dose amoxicillin-clavulanate (amoxicillin dosed at
2 g twice daily or 90 mg/kg daily given twice daily) for 7
to 10 days
● Doxycycline
● Levofloxacin/moxifloxacin
In penicillin allergic patients, what antibiotics are recommended by the IDSA for adults?
● Doxycycline ● Levofloxacin ● Moxifloxacin ● Cefixime/cefpodoxime and Clindamycin Not macrolides or trimethoprim-sulfamethoxazole because of concern for resistance
According to the IDSA, for a patient being treated
with either a first- or second-line antibiotic for
acute bacterial rhinosinusitis (who does not
demonstrate symptomatic improvement or presents
with worsening symptoms after 3 to 5 days of
treatment), is switched to a different class of
antibiotic or broader coverage, and again demon-
strates no improvement or worsening after 3 to 5
days, what additional steps should be considered?
● CT and/or MRI (CT preferred) to look for anatomical
problems and suppurative complications
● Sinus culture to help direct pathogen specific antimicro-
bials
● Consider referral to infectious disease or allergy specialist
(and ear, nose, and throat [ENT] specialist).
When should surgical intervention be considered
for patients with acute rhinosinusitis?
Only if complications are present that would benefit from
surgical intervention or for recurrent acute rhinosinusitis
thought to be caused by an anatomical abnormality
What criteria are required for diagnosis of CRS
according to the European Position Paper on
Rhinosinusitis and Nasal Polyposis (2007 and 2012)
and the Clinical Practice Guidelines: Adult Sinusitis
(2007)?
Two or more of the following symptoms for ≥ 12 weeks:
● At least one of (1) nasal blockage/obstruction/congestion
or (2) nasal discharge (anterior or posterior, mucopur-
ulent)
● Facial pain/pressure or fullness (less common in patients
with NP)
● Decreased or loss of smell (more common in patients
with NP)
● Objective evidence of inflammation
● Purulent mucous or edema in the middle meatus or
ethmoid region
● NP
● CT without contrast demonstrating inflammation in the
paranasal sinuses (more commonly recommended for
endonasal tumors)
During the workup for CRS or recurrent acute
rhinosinusitis, what comorbidities should be
investigated that might modify management?
● Allergic rhinitis ● Cystic fibrosis ● Immunocompromise ● Ciliary dyskinesia ● Anatomical abnormality
What is the classic triad associated with
Kartagener syndrome?
● Situs inversus
● Bronchiectasis
● CRS
Note: Caused by a dynein arm defect; autosomal recessive
What percentage of patients with CRS will also
have asthma?
50%
If patients with CRS do not improve with standard
therapy, allergy testing may be considered because
60% of these patients have significant allergies.
What are the most common allergens implicated?
Perennial allergens: Dust mites, cockroaches, pet dander,
fungi
What diagnosis is given to patients who have
aspirin sensitivity, NP, and asthma?
Samter triad
