What's trending in Sinusitis

Latest updates on the approach to a patient with rhinosinusitis including management decisions to be made.

1. Supervisor : Rebecca B. Newman, MD Attending, General Internal Medicine Assistant Professor of Clinical Medicine, NYMC Medical Director, APCC, Cedarwood Hall/ WMC Presenter : Jagjit Khosla, MBBS (simply “Jags”) PGY1, Internal Medicine, NYMC at WMC What’s trending in Sinusitis

2. In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache, and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve What is the diagnosis?

3. In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache, and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve What is the diagnosis? Persistent viral upper respiratory infection Acute Bacterial rhinosinusitis Acute Viral rhinosinusitis Subacute Bacterial rhinosinusitis Subacute viral rhinosinusitis Chronic rhinosinusitis

4. Defining and Diagnosing… Rhinosinusitis By Jagjit Khosla 1

5. Classification of Rhinosinusitis Acute Subacute Chronic 4 Weeks or less Between 4 to 12 weeks 12 Weeks or more

6. Definition of Acute Rhinosinusitis Purulent Nasal Discharge Cloudy or colored Anterior or Posterior + OR Nasal obstruction Congestion Blockage Stuffiness Facial Pain-Pressure-Fullness Anterior Face Periorbital region Headache

7. Definition of Viral URTI Purulent Nasal Discharge Cloudy or colored Anterior or Posterior + OR Nasal obstruction Congestion Blockage Stuffiness Facial Pain-Pressure-Fullness Anterior Face Periorbital region Headache

8. Types of Acute Rhinosinusitis Acute Bacterial Rhinosinusitis Less than 10 days with double worsening (after initial improvement) 10 days or more with symptoms persisting/ worsening Acute Viral Rhinosinusitis Less than 10 days without worsening 10 days or more with symptoms decreasing Most commonly - Rhinovirus, influenza, and parainfluenza Most commonly - Strep pneumoniae, H. influenzae, and Moraxella catarrhalis

9. D iagnosing Acute rhinosinusitis Purulent Nasal discharge < 4 weeks Nasal obstruction or Facial pain-pressure-fullness No Yes Viral URTI < 10 Days No Yes Worsening Improving No Yes Acute Viral Sinusitis Acute Bacterial Sinusitis No Yes Acute Bacterial Sinusitis 1 2 3

10. In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache , and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve Purulent Nasal discharge < 4 weeks Nasal obstruction or Facial pain-pressure-fullness No Yes Viral URTI < 10 Days No Yes Worsening Improving No Yes Acute Viral Sinusitis Acute Bacterial Sinusitis No Yes Acute Bacterial Sinusitis    1 2 3

11. In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache, and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve What is the diagnosis? Persistent viral upper respiratory infection Acute Bacterial rhinosinusitis Acute Viral rhinosinusitis Subacute Bacterial rhinosinusitis Subacute viral rhinosinusitis Chronic rhinosinusitis 

12. Acute rhinosinusitis MC cause - viral URTI 0.5%-2.0% of Acute viral sinusitis progresses to acute bacterial sinusitis 85% resolve within 7-15 days without antibiotic P/E – Altered speech, Erythema/ edema over cheek bone, Sinus tenderness, Purulent discharge from nose or posterior pharynx.

13. Acute rhinosinusitis Diagnostic testing not indicated unless complications suspected (orbital cellulitis, subperiosteal abscess) CT scan is the best imaging method Never culture nasal discharge. Exception- DM/Immunocompromised not responding to Amox-clav for 72 hours (Think atypical or resistant organism), OR Temp >39C, Nasal crusting or severe facial pain (Think fungal) Sinus biopsy or aspirate is the gold standard.

14. Acute rhinosinusitis Coronal image from a CT of the paranasal sinuses showing mucosal edema (arrows) and thick secretions (asterisks)

15. In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache, and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve What is the diagnosis? Acute Bacterial rhinosinusitis  How will you manage this patient? Wait and See Antibiotic therapy Analgesics Nasal Glucocorticoids Nasal irrigation Oral Glucocorticoids Nasal Decongestant/Anti-histamines/Guaifenesin

16. 2 Managing… Rhinosinusitis By Jagjit Khosla

17. Management of Acute Viral Sinusitis No Antibiotics Analgesic and antipyretic (NSAIDS, Acetaminophen) Intranasal glucocorticoids. M ajor S/e: Epistaxis, Headache, Nasal itching Saline irrigation M ajor S/e: Nasal discomfort and irritation Nasal decongestant (Oxymetazoline)? A ntihistamines ? Guaifenesin?

18. Management of Acute Bacterial Rhinosinusitis Many guidelines American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) Infectious Diseases Society of America (IDSA) American College of Physicians (ACP) and Centers for Disease Control and Prevention (CDCP) Canadian Clinical Practice Guideline European Position Statement

19. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Pen-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

20. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Pen-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

21. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Pen-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

22. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Penicillin-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

23. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Penicillin-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

24. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Penicillin-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

25. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Penicillin-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

26. Management of Acute Bacterial Rhinosinusitis AAO-HNS IDSA Canadian European Initial Therapy Watchful waiting or Antibiotics Antibiotics Watchful waiting for mild; Antibiotics for severe Watchful waiting for mild; Antibiotics for severe First line Antibiotics Amoxicillin or Amox-Clav Amox-Clav Amoxicillin - Antibiotics if Penicillin-allergic Doxycycline or Quinolone Doxycycline or Quinolone Macrolide or TMP-SMX - Topical Glucocorticoids Optional Recommended Recommended Recommended Nasal Irrigation Optional Recommended Optional Limited effect Oral Glucocorticoids Not recommended - - Optional for severe illness Initial Failure of Treatment 7 Days 3-5 days 72 hours 48 hr if Severe; 14 days if Mild-Mod

27. Management of Acute Bacterial Rhinosinusitis ACP and CDCP recommendations for antibiotics use in Acute rhinosinusitis Persistent symptoms for more than 10 days Onset of severe S/S of high fever (>39 C) AND purulent nasal discharge or facial pain lasting for 3 days Double worsening

28. Management of Acute Bacterial Rhinosinusitis Acute Bacterial Rhinosinusitis No Complication Suspected? Yes Radiological Imaging Manage Complication and ABRS Recommend Symptomatic Rx; Shared Decision making Watchful Waiting Amoxicillin-Clavulanate or Doxycycline (5-10 d) Improvement in 7 Days Improvement in 7 Days Yes No Yes No Rule out complications and other causes If diagnosis of ARBS confirmed, switch to Quinolones

29. Management of Acute Bacterial Rhinosinusitis Antibiotic Therapy for ABRS Risk factors for resistance? Pen- nonsusceptible S. Pneumo >10% Age > 65y Hospitalized Antibiotics use in previous month Immunocompromise Comorbidity (DM, Cardiac, Hepatic, Renal) Severe infection No Penicillin Allergy Penicillin Allergy No Yes Amoxicillin-Clavulanate (Standard dose) 500mg/125mg three times a day 875mg/125mg twice daily Amoxicillin-Clavulanate (High Dose) 2000mg/125mg ER twice daily Doxycycline : 100mg BD or 200mg daily ---------------- Clindamycin 150mg/300mg Q6H + 3 rd Gen. Cephal . ( Cefixime 400mg daily or Cefpodoxime 200mg BD) ----------------- Levofloxacin 500mg daily or Moxifloxacin 400mg daily

30. Management of Acute Bacterial Rhinosinusitis Risk factors for resistance? Pen- nonsusceptible S. Pneumo >10% Age > 65y Hospitalized Antibiotics use in previous month Immunocompromise Comorbidity (DM, Cardiac, Hepatic, Renal) Severe infection No Penicillin Allergy Penicillin Allergy No Amoxicillin-Clavulanate (Standard dose) 500mg/125mg three times a day 875mg/125mg twice daily Amoxicillin-Clavulanate (High Dose) 2000mg/125mg ER twice daily Doxycycline : 100mg BD or 200mg daily ---------------- Clindamycin 150mg/300mg Q6H + 3 rd Gen. Cephal . ( Cefixime 400mg daily or Cefpodoxime 200mg BD) ----------------- Levofloxacin 500mg daily or Moxifloxacin 400mg daily IF PREGNANT Antibiotic Therapy for ABRS Yes

31. Management of Acute Bacterial Rhinosinusitis Antibiotics use in Acute Rhinosinusitis 7 3% to 85% Acute sinusitis resolves without antibiotics NNT for antibiotics vs placebo is 7-18 NNH for antibiotics related adverse effects is 8-12 Incidences of suppurative complications of acute sinusitis (Cellulitis, Meningitis, orbital or intracranial abscess) similar in Antibiotics and placebo groups. No difference in efficacy between Amox-Clav , Doxy or Quinolones Amox vs Amox-Clav comparison trials lacking. Macrolides and TMX-SMX NOT recommended because of high resistance (40-50%) Strep. Pneumo

32. Management of Acute Bacterial Rhinosinusitis When to refer to Otolaryngologist Refractory illness Recurrent Acute Bacterial sinusitis 3 episodes in 6 months 4 episodes in year Other causes ( tumors or structural abn .) suspected

33. Acute Rhinosinusitis

34. Acute Rhinosinusitis

35. Acute Rhinosinusitis

36. Wait and See Antibiotic therapy Analgesics Nasal Glucocorticoids Nasal irrigation Oral Glucocorticoids Nasal Decongestant/Anti-histamines/Guaifenesin In the Clinic… 28 year old woman with nasal discharge for 12 days 12 days ago, acute onset nasal discharge, Frontal headache, and Temp 39.5 C Temp normalized within 2 days But, she has bothersome nasal congestion and purulent post nasal drip that does not improve What is the diagnosis? Acute Bacterial rhinosinusitis  How will you manage this patient?     

37. 3 Chronic Rhinosinusitis By Jagjit Khosla

38. Definition of Chronic Rhinosinusitis Chronic rhinosinusitis 1. Two or more of following for 12 weeks or longer Mucopurulent drainage Nasal obstruction Facial pain-pressure-fullness Decreased sense of smell AND 2. Documented Inflammation Purulent mucus or edema Nasal polyps Radiographic imaging

39. Subtypes of Chronic Rhinosinusitis CRS with Nasal Polyposis – 25% Bilateral nasal polyps in the middle meatus Associated with asthma and adverse reactions to aspirin and other NSAIDs Aspirin-exacerbated respiratory disease (AERD) – Asthma + CRS with NP + Aspirin Sensitivity Allergic Fungal Rhinosinusitis – 10% Young patients from the southern United States. Presents dramatically with complete nasal obstruction, gross facial asymmetry, and/or visual changes Allergic mucin that contains viable fungal hyphae (fungal staining or culture) IgE -mediated allergy to one or more fungi CRS without Nasal Polyposis – 65%

40. Chronic Rhinosinusitis with Nasal Polyps Chronic rhinosinusitis with Nasal polyps Nasal Polyps appear as fixed, glistening, gray or white, mucoid masses * *

41. Chronic Rhinosinusitis without Nasal Polyps Chronic Rhinosinusitis without Nasal polyps Ethmoid Sinus Maxillary Sinus Maxillary Sinus Middle Turbinate Inferior Turbinate * * *

42. Chronic Rhinosinusitis – Diagnosis & Mx Signs and Symptoms of CRS Documented Sinonasal inflammation? Anterior Rhinoscopy , Nasal Endoscopy or CT Paranasal sinuses Chronic Rhinosinusitis Confirm the presence or absence of Nasal Polyps Recommend Saline Nasal irrigation +/- topical intranasal corticosteroids Do not prescribe topical or systemic antifungal therapy Assess for chronic conditions like asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia May obtain testing for allergy and immune function

43. ? Questions By Jagjit Khosla

44. MKSAP Question A 68-year-old woman is evaluated for sinus symptoms of 2 to 3 days’ duration. She reports nasal congestion and a whitish nasal discharge, a full sensation over both maxillary sinuses, and pain in her upper teeth. She does not have fever or ear or throat pain and has had no sick contacts. Medical history is significant for hypertension and type 2 diabetes mellitus. She has no known drug allergies. Her medications are fosinopril and metformin. On physical examination, temperature is 37.2 °C (98.9 °F), blood pressure is 122/72 mm Hg, and pulse rate is 68/min. BMI is 26. There is tenderness to palpation over both maxillary sinuses. Dentition and tympanic membranes are normal. The oropharynx is mildly erythematous without exudates. There is no cervical lymphadenopathy. The lungs are clear. The remainder of the examination is normal. Which of the following is the most appropriate management? Amoxicillin-clavulanate D oxycycline S inus CT Scan S upportive Care 

45. MKSAP Question Key Point Intranasal glucocorticoids, antihistamines, and topical decongestants are all appropriate for initial treatment of acute sinusitis; antibiotics should not be used initially. This patient, who has acute sinusitis, should be managed with supportive care . Acute sinusitis is most commonly caused by viral infections associated with the common cold, and it has a bacterial etiology in only a small percentage of cases. Acute sinusitis is characterized by symptoms of nasal congestion and obstruction; facial pain, pressure, and fullness that generally worsen when bending forward; headache; purulent nasal discharge; and maxillary tooth pain. When caused by viral infection, fever may be present within the first 24 to 48 hours of symptom onset , often associated with other symptoms such as myalgia and fatigue, but temperature normalizes after this time period. Bacterial sinusitis is more likely if there are severe symptoms associated with a high fever for at least 3 or 4 consecutive days following the onset of illness or if symptoms are persistent (lasting more than 10 days). Initial treatment of acute sinusitis is focused on symptom relief with analgesics, decongestants (systemic or topical), antihistamines, intranasal glucocorticoids, and nasal saline irrigation, and these treatment options would be the most appropriate therapy in this patient who does not have findings concerning for a possible bacterial etiology. Antibiotics are not indicated in this patient at this time. Although more than 90% of cases of acute sinusitis are viral in origin, antibiotics are regularly prescribed for patients presenting with acute sinusitis symptoms. Antibiotics should be reserved for patients with persistent and severe symptoms (such as high fever and marked facial pain), progressively worsening symptoms, or failure to improve after 10 daysof supportive care . If antibiotics are indicated, both amoxicillin-clavulanate and doxycycline would be appropriate first-line agents. Although this patient has purulent nasal discharge, the acute nature of the symptoms makes antibiotics inappropriate at this time. Imaging with plain radiographs or CT is rarely needed in acute sinusitis and does not help in distinguishing a bacterial from viral cause.

46. A Presentation by Jagjit Khosla