First Aid, Chapter 7 Hypersensitivity Disorders, Sinusitis

Question 1

What percent of adults are diagnosed with rhinosinusitis every year? What age group is most common? What gender?

Answer 1

1 in 7 older than 18 every year, most commonly adults between 45-75, higher in females.

Question 2

What is required to make a diagnosis of acute rhinosinusitis? What are the major and minor symptoms?

Answer 2

Diagnosis for ARS requires at least 2 major symptoms or 1 major and at least 2 minor symptoms.

Major symptoms include:

• Purulent anterior or posterior (postnasal drip) rhinorrhea
• Nasal congestion and/or obstruction
• Facial congestion and/or “fullness”
• Facial pain/ pressure
• Fever
• Hyposmia and/or anosmia

Minor symptoms include:

• Headache
• Ear pain and/or pressure and/or fullness
• Bad breath
• Dental pain
• Fatigue
• Cough

Question 3

What are three ways to distinguish acute bacterial rhinosinusitis from viral rhinosinusitis?

Answer 3

• Persistent signs/symptoms compatible with ARS for more than 10 days, no sign of clinical improvement
• Severe signs/symptoms (fever >102oF) and either purulent rhinorrhea or facial pain lasting for at least 3–4 consecutive days (at start of illness)
• URI symptoms for 5–6 days followed by worsening signs/symptoms (new fever onset, headache or increase in rhinorrhea)—this is known as “double sickening.”

Question 4

What are indications for CT sinus?

Answer 4

ABRS with suspected suppurative complications, recurrent ARS or sinusitis w/ complications

Question 5

When should an ENT consult for culture of aspirate of sinus be done for sinusitis? Endoscopic culture of middle meatal complex?

Answer 5

Cases refractory to standard treatment. Children should have direct sinus aspiration, adults only should have endoscopic culture of the middle meatal complex?

Question 6

What are indications to treat ABRS with high dose amoxicillin-clavulanate?

Answer 6

Patients living in areas with high endemic rates of invasive resistant S. pneumoniae, fever >102oF, threat of suppurative complications, participating in day care, younger than 2 years or older than 65 years of age, recently hospitalized, treated with antibiotics in preceding month, or those who are immunocompromised.

Question 7

What antitbiotics should PCN allergic adults be treated for ABRS? children?

Answer 7

Adults - fluoroquinolone or doxy

Children - type 1 reaction should be treated with levaquin, other reactions clindamycin w/ 3rd generation cephalosporin. Levaquin not licensed for use in children.

Empiric macrolides and bactrim not recommended due to high resistance. Coverage should be broadened in those who do not improve or worsen in 3-5 days.

Question 8

What is the definition of CRS?

Answer 8

an inflammatory (rather than infectious) condition that is defined by radiographic evidence of sinusitis with symptoms persisting >8– 12 weeks. The presence of >2 symptoms (i.e., nasal obstruction/congestion, facial pain/pressure/fullness, purulent anterior/posterior rhinorrhea, hyponosmia /anosmia) for >12 weeks in conjunction with documented inflammation (i.e., purulence or edema in middle meatus or ethmoid region, polyps in middle meatus or nasal passages, and/or imaging documenting paranasal sinus inflammation) is highly sensitive for diagnosing CRS.

Question 9

Which inflammatory mediators are elevated in ARS?

Answer 9

IL-1B, IL-6, and especially IL-8

Question 10

Which of the following is a risk factor for the development of sinusitis: concha bullosa or Haller cell?

Answer 10

Haller cell—a pneumatized ethmoid cell that blocks the ostiomeatal complex. Concha bullosa, an aerated middle turbinate, is not a risk factor.

Question 11

What factors are more common in CRSwNP than w/o?

Answer 11

• Anosmia
• Dust mite sensitization
• Eosinophils on biopsy
• Asthma
• AERD
• Allergic fungal rhinosinusitis (AFRS)

Question 12

What is another name for CRS w/ NP?

Answer 12

hyperplastic eosinophilic sinusitis

Question 13

What percentage of sinusitis is CRS w/ NP?

Answer 13

1/3.

Question 14

Is CRS w/ NP associated with bacterial causes?

Answer 14

CRS with NPs is not usually associated with bacterial causes, except in cases of local production of staphylococcal enterotoxins in NPs, which may increase local IgE production and eosinophilic inflammation via Th2 skewing.

Question 15

What symptoms are more common in CRS w/ NP vs. w/o NP? and vice versa?

Answer 15

Both CRS with and without NPs have significant nasal obstruction/congestion and rhinorrhea. In CRS without NPs there is a higher rate of facial pain. Patient with CRS with NPs tend to have more problems with hyponosmia/anosmia, whereas these is rare in CRS without NPs.

Question 16

Identify which of these inflammatory mediators are increased or decreased in both CRS w/o NP and CRS w/ NP. IL-3, GM-CSF, eosinophil cationic protein, IL-5, IgE, eotaxin, LTC4/D4/E4, LTB4, PGE2, lipoxin A4

Answer 16

Table 7-2. Summary of Inflammatory Mediators in CRS with and Without Nasal Polyps  
CRS wo NP : CRS with NP 
IL-3         ↑↑                 – 
GM-CSF ↑                   – 
Eosinophil cationic protein                  ↑                                  ↑↑ 
IL-5       –                    ↑↑ 
IgE        –                    ↑↑ 
Eotaxin –                    ↑↑ 
LTC4/D4/E4 ↑            ↑↑ 
LTB4             ↑             ↑ 
PGE2           ↑↑             ↓ 
Lipoxin A4    ↑            ↑↑