Sinusitis acute versus chronic
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This document contains information from a presentation on sinusitis by Dr. Ahmad Sultan. It discusses: 1) The classification and symptoms of acute and chronic sinusitis and allergic rhinitis. Complications of acute sinusitis include preseptal cellulitis and orbital cellulitis. 2) Recommended treatments for acute sinusitis including analgesics, saline irrigation, intranasal glucocorticoids, oral and intranasal decongestants, and amoxicillin-clavulanate antibiotics for suspected bacterial infections. 3) Two case summaries of patients presenting with symptoms of acute and allergic sinusitis and the relevant history, potential diagnoses, and treatment recommendations.
Sinusitis acute versus chronic
- 1. AHMAD SALADDIN SULTAN M.B.Ch.B, M.R.C.E.M, F.J.M.C.H.S.(A&E) Specialist Emergency Medicine
- 2. I Dr. AHMAD SULTAN DO NOT have a financial interest/arrangement or affiliation with anyone in relation to this program/presentation/organization that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
- 3. -Assess the clinical findings, symptoms, and risk factors associated with the diagnosis of acute & chronic sinusitis. -Classify sinusitis and put a management plan accordingly. -Identify signs of potentially dangerous complications of acute sinusitis.
- 4. The four paired sinuses or air cavities can be referred to as: - Ethmoid sinus cavities which are located between the eyes. - Frontal sinus cavities which can be found above the eyes (more in the forehead region). - Maxillary sinus cavities are located on either side of the nostrils (cheekbone areas). - Sphenoid sinuses that are located behind the eyes and lie in the deeper recesses of the skull.
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- 6. The presence of sinus cavities within the cranial bone (skull) is essential for the following reasons: - Sinus cavities allow for voice resonance. - They help filter and add moisture to any air that is inhaled through the nasal passages. - Sinus Cavities provide a means to lighten the overall weight of the skull.
- 7. Acute Rhinosinusitis (ARS) : Is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks. The term “Rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa.
- 8. Acute rhinosinusitis (ARS) is a common problem. Each year, about one in seven or eight persons in the United States and other Western countries will have an episode of sinusitis. Incidence is higher in women than men. Among adults, incidence is highest among those aged 45 to 64 years.
- 9. older age, smoking, air travel, exposure to changes in atmospheric pressure (eg. deep sea diving), swimming, asthma and allergies, dental disease, and immunodeficiency.
- 10. A-Classification of rhinosinusitis is based upon symptom duration: -Acute rhinosinusitis – Symptoms for less than four weeks. -Subacute rhinosinusitis – Symptoms for 4 to 12 weeks. -Chronic rhinosinusitis – Symptoms persist greater than 12 weeks. -Recurrent acute rhinosinusitis – Four or more episodes of ARS per year, with interim symptom resolution. B-ARS is further classified based on etiology and clinical manifestations: -Acute viral rhinosinusitis (AVRS). -Uncomplicated acute bacterial rhinosinusitis (ABRS) – ARS with bacterial etiology without clinical evidence of extension outside the paranasal sinuses and nasal cavity (eg, without neurologic, ophthalmologic, or soft tissue involvement). -Complicated acute bacterial rhinosinusitis – ARS with bacterial etiology with clinical evidence of extension outside the paranasal sinuses and nasal cavity.
- 11. Symptoms: -Pain over cheek and radiating to frontal region or teeth, increasing with straining or bending down. -Redness of nose, cheeks, or eyelids. -Tenderness to pressure over the floor of the frontal sinus immediately above the inner canthus. -Referred pain to the vertex, temple, or occiput. -Postnasal discharge. -blocked nose. -Persistent coughing or pharyngeal irritation. -Facial pain -Hyposmia.
- 12. Signs: -Purulent nasal secretions. -Purulent posterior pharyngeal secretions. -Mucosal erythema. -Peri-orbital edema. -Tenderness overlying sinuses. -Facial erythema.
- 13. Acute viral rhinosinusitis Acute viral rhinosinusitis (AVRS) is diagnosed clinically when patients have <10 days of symptoms consistent with ARS that are not worsening. Acute bacterial rhinosinusitis The following criteria are used to diagnose acute bacterial rhinosinusitis (ABRS) which are supported by the guidelines from the Infectious Diseases Society of America and the American Academy of Otolaryngology-Head and Neck Surgery : - Persistent symptoms or signs of ARS lasting 10 or more days without evidence of clinical improvement or - Onset of severe symptoms or signs of high fever (>39°C or 102°F) and purulent nasal discharge or facial pain for at least three to four consecutive days at the beginning of illness or - Symptoms of a typical viral upper respiratory infection that are slowly improving but then worsen again ("double-worsening") with more severe symptoms and signs (new-onset fever, headache, nasal discharge) after five to six days.
- 14. Signs and symptoms — Allergic rhinitis presents with paroxysms of sneezing, rhinorrhea, nasal obstruction, and nasal itching. Postnasal drip, cough, irritability, and fatigue are other common symptoms. Some patients experience itching of the palate and inner ear. Those with concomitant allergic conjunctivitis report bilateral itching, tearing, and/or burning of the eyes. Allergic Rhinitis occurs when the body's immune system over-responds to specific, non-infectious particles such as plant pollens, molds, dust mites, animal hair, industrial chemicals (including tobacco smoke), foods, medicines, and insect venom. Seasonal allergic rhinitis occurs in late summer or spring. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.
- 15. -Preseptal cellulitis. -Orbital cellulitis. -Subperiosteal abscess. -Osteomyelitis of the sinus bones. -Meningitis. -Intracranial abscess. -Septic cavernous sinus thrombosis.
- 16. In general no diagnostic evaluation is required and the diagnosis is clinical based, but radiological evaluation and microbiology indicated in cases listed below and should referred to the ENT Clinic or Emergency Department: -Persistent, high fevers > (39°C). -Severe and persistent headache. -Periorbital edema, inflammation, or erythema. -Vision changes (double vision or impaired vision). -Abnormal extraocular movements. -Proptosis. -Ophthalmoplegia (pain with eye movement). -Cranial nerve palsies. -Altered mental status. -Neck stiffness or other meningeal signs. -Papilledema or other sign of increased intracranial pressure.
- 17. -Microbiologic testing : The most common bacteria associated with ABRS are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, with the first two comprising approximately 75 percent of cases of ABRS.
- 18. -Imaging: Computed Tomography (CT; with contrast) or a Magnetic Resonance Imaging (MRI; without and with contrast) of the head including the paranasal sinuses.
- 20. Non-pharmacologic self-care: - Warm moist air. - Nasal saline. - Hydration. - Warm facial packs. - Avoidance of nasal irritants (e.g. Cigarette smoke, indoor and outdoor air pollutant).
- 21. • Symptomatic therapies: Analgesics and antipyretics — OTC analgesics and antipyretics such as nonsteroidal anti-inflammatory drugs and acetaminophen (650 mg q4h or 1,000 mg q6h dose for adults )can be used for pain and fever relief as needed. Saline irrigation — Mechanical irrigation with buffered, physiologic, or hypertonic saline may reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections The benefits of saline irrigation: 1. Saline (saltwater) washes the mucus and irritants from your nose. 2. The sinus passages are moisturized. 3. Studies have also shown that a nasal irrigation improves cell function.
- 22. Others: Intranasal glucocorticoids: Studies have shown small symptomatic benefits and minimal adverse effects with short-term use of intranasal glucocorticoids (budesonide , fluticasone) . Oral decongestants: Oral decongestants like pseudoephedrine may be useful when Eustachian tube dysfunction is a factor for patients with AVRS. These patients may benefit from a short course (three to five days) of oral decongestants. Intranasal decongestants: Intranasal decongestants are often used as symptomatic therapies by patients. These agents, such as e.g. phenylephrine, oxymetazoline, xylometazolin, may provide a subjective sense of improved nasal patency, topical decongestants should be used sparingly for no more than three consecutive days to avoid rebound congestion, addiction, and mucosal damage associated with long-term use.
- 23. • Antibiotic: Which depending on patient presentation and co-morbidities. Initial empiric treatment with: - Amoxicillin- clavulanate 625mg orally three times daily for seven days. - Second – line empiric therapy: High dose Amoxicillin- clavulanate (2000mg/125mgorally twice daily) or a respiratory fluoroquinolone Levofloxacin 500mg orally once daily or Moxifloxacin 400mg orally once daily) for five to seven days. For penicillin- allergic patients, Doxycycline 100mg orally twice daily or 200mg orally daily for five to seven days. • Follow-Up Care: if not improved within 72 hours.
- 26. Thirty years old female patient presented with history of Ten days of common cold with clear nasal discharge and then she started to feel frontal headache which increase while bending forward, nasal blockage with purulent discharge which increased three days ago, on examination found tenderness when do percussion on frontal area, Vitals BP:120/78mmHg, PR:95B/M, RR:18 and temp. 39.1C: Important history points? Investigations? Provisional Diagnosis? Treatments? Disposition?
- 27. Thirty Eight Years female patient presented with clear nasal discharge for the last six days with frontal headache increase with Sojood and decreased sense of smell. Vitals is BP:110/76mmHg, PR:82B/M, RR:14, Temp.:37.7C: Points of History? Investigations? Provisional Diagnosis? Treatments? Disposition?
- 28. Twenty Seven Years Female patient presented with clear nasal discharge for the last 9 days with nasal blockage, congestion, sneezing, nasal itching associated with bilateral conjunctivitis and she had same attacks in the previous years specially at spring seasons. Vitals is BP:105/73mmHg, PR:80B/M, RR:12, Temp.:36.7C: Points of History? Investigations? Provisional Diagnosis? Treatments? Disposition?
- 29. Fifty Three years old female brought by her son with history of breast cancer on chemotherapy presented with complaining clear nasal discharge and generalized body aches for the last two weeks then headache start to appear specially at frontal area since Eight days which intensity increase while bending forward and purulent nasal discharge today she start to feel sever headache with repeated vomiting since 10 hours and also report intolerance to perception of light and neck stiffness. Vital signs are: BP:140/98mmHg, PR:55 B/M, RR:21 Irregular, Temp.:39.5C: Points of History? Investigations? Provisional Diagnosis? Treatments? Disposition?
- 30. After she reached Emergency what are steps they will do after taken history and examinations: