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

− first generation antihistamines help

− because of their anticholinergic activity

− alkylamines produce the least sedation and most anticholinergic activity

− ex: chlorpheniramine and brompheniramine

− majority of OTC meds contain chlorpheniramine

− 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

− antisecretory agent, so causes drying of secretions

− including saliva

− does not significantly cross blood brain barrier

− so sedation is unlikely

− may be combined with:

− 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)

− antihistamine (ex. AlleRx DF Dose Pack)

− antihistamine/decongestant (ex. Dallergy)

(c) Anticholinergic spray

− Atrovent 0.06% indicated for rhinorrhea of colds

− in adults and children 6 years and up

(d) Oral decongestants

− 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

− in children 2-6 years old, consider prescription for tetrahydrozoline (Tyzine) QID

− or, in select cases, diluted Afrin

− more effective with less side effects than oral decongestants

− must emphasize need to limit duration of use to 5 days or less

(f) Expectorants

− 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

− lasting at least 7-10 days

(b) persistency of symptoms

− not improving after 7-10 days

(c) pattern of symptoms

− worsening of symptoms after initial improvement (i.e “double sickening”)

d) type of symptoms

− persistent purulent nasal discharge

− facial pain/pressure

− especially localized facial pain and/or maxillary teeth pain

− nasal obstruction

− 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

2. Physical Exam

(a) Anterior rhinoscopy

− pus in the nasal cavity is supportive, but not conclusive, for bacterial infection

− purulent drainage may also be seen in oropharynx

(b) Percussion (i.e. tap tenderness)

− not helpful, unless definitely abnormal

(c) Transillumination

− in adults, helpful if done with proper technique and if definitely normal or abnormal

− in children, no proven benefit

(d) Nasal endoscopy

− helpful but requires expertise, special equipment, and patient cooperation

3. X-Ray

(a) Plain films

− correspond to maxillary sinus aspirate in only 70% of cases

− findings of “air-fluid level” and “maxillary opacification” are relatively specific for bacterial maxillary sinusitis

− including the finding of “mucosal thickening” increases the sensitivity, but

decreases the specificity of plain films

− the absence of all three of these x-ray findings strongly suggests against

bacterial maxillary sinusitis

−extremely poor in evaluating the ethmoid sinuses

− a normal plain film may rule out maxillary sinusitis, but not ethmoid sinusitis

(b) CT

− “gold standard” for detecting inflammation, but not necessarily a bacterial infection

− 90% of viral infections have abnormal mucosal thickening on a sinus CT

− 30% of reportedly asymptomatic patients have abnormal findings on a sinus CT

4. Antibiotic Treatment

(a) Need for antibiotics

− spontaneous resolution rate of clinically determined sinusitis is around 66%

− benefits of antibiotic:

− more rapid resolution of symptoms

− 50% reduction in clinical failures

− recent position paper (Otol-HNS 2007; 137:S1-S31) endorsed watchful waiting as an

option (not recommendation) if:

− mild illness

− 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

− refer to “Viral Rhinosinusitis” section

(b) Oral decongestant

− refer to “Viral Rhinosinusitis” section

(c) Antihistamine

− 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

− for guaifenesin to be effective, need maximum dosing

− 2-6 years old……total daily dose of 600 mg

− 6-12 years old..…total daily dose of 1200 mg

− 12 years and up…total daily dose of 2400 mg

− products that provide 2400 mg for a day

− Robitussin (guaifenesin 100 mg/5 cc) 30 cc QID

− Mucinex (guaifenesin 600 mg) 2 tabs BID

− generic guaifenesin tabs (400 mg) 2 tabs TID

− immediate release and least expensive

(e) Saline wash

− instead of 1-2 sprays, “wash” with

− multiple squirts from OTC nasal spray container

− lavage bottle (ex. )

− neti pot

− commercial canisters which “wash”

− Simply Saline (available at most drugstores)…either normal or hypertonic saline

− ENTsol spray (available at )...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

− appear safe to use even in the presence of a bacterial infection

− Cochrane review in 2007 supports their use

(g) Oral steroids

− 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:

-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

-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)

-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

6. 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

7. 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

8. Cromolyn sodium spray (Nasalcrom)

-OTC

-excellent safety profile, even in pregnancy

-frequent dosing required (t.i.d.-q.i.d.)

9. 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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