2. 2
INTRODUCTION
Acute bacterial rhinosinusitis (ABRS) is an infection and
inflammation of the paranasal sinuses that occurs as a
result of bacterial colonization, typically following a
viral upper respiratory tract infection.
It is characterized by the presence of symptoms lasting
10 days or more, including purulent nasal congestion,
drainage, facial pain, postnasal drip, hyposmia/anosmia
and fever.
• It can involve one or more of the sinuses, including
the maxillary, frontal, ethmoid, or sphenoid sinuses.
3. 3
ETIOLOGY
• Most cases of ABRS are preceded by a viral URI
• The most common bacterial pathogens include: Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis
• Less commonly, the following bacteria may also be implicated:
Staphylococcus aureus (including MRSA), Anaerobic bacteria.
• Sinus Obstruction: Any factor that obstructs sinus drainage can predispose
an individual to bacterial infection such as allergic rhinitis, nasal polyp and
environmental irritants(smoke, pollutants)
• Immunocompromised states(HIV/AIDS, chemotherapy and chronic
conditions like asthma, cystic fibrosis and smoking may increase the
susceptibility to ARBS.
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PREVALENCE
• Most ARS cases are viral (90%-98%), while bacterial infections are 2%-10%.
• Secondary bacterial infection following viral URI occurs in 0.5%-2% of
adult cases.
5. PREDISPOSING FACTORS
• Allergic/non-allergic rhinitis, nasal polyps,
trauma, dental infections, immunodeficiency
or other factors that lead to inflammation of
the nose and paranasal sinuses.
• Rhinosinusitis is found more commonly in
conditions like tumors, Wegener’s
granulomatosis, HIV, Kartagener’s syndrome,
immotile cilia syndrome, and cystic fibrosis
increase risk.
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SIGNS AND SYMPTOMS
1. Nasal congestion.
2. Purulent nasal discharge.
3. Facial pain or pressure.
4. Fever.
5. Cough.
6. Fatigue.
7.Maxillary dental pain.
8.Ear pressure or fullness.
9.Hyposmia or anosmia
10.Early morning headache due to the
involvement of frontal sinuses
11.Pain with Movement of eye due to the
involvement of ethmoid sinuses
7. PATHOPHYSIOLOGY
Predisposing factors
• Allergic rhinitis
• Anatomical abnormalities like nasal
polyp, deviated septum
• Environmental irritants like smoking,
pollution impaired the mucociliary
clearance.
• Immunodeficiencies like diabetes, hiv,
immunosuppressive drugs weakens the
immune system thereby increasing the
risk of infection.
Microbial Invasion
Viral URI impairs the normal mucus
clearance providing an ideal
environment for bacterial proliferation.
Common pathogens include:
Streptococcus pneumoniae (most
common).
Haemophilus influenzae.
Moraxella catarrhalis (especially in
children).
8. Inflammatory Cascade
Bacterial colonization leads to immune
cell recruitment and the release of pro-
inflammatory cytokines, which causes:
Mucosal edema: Further narrows sinus
openings.
Hypersecretion of mucus: Causes nasal
discharge and blockage.
Pus formation: containing dead
cells(dead neutrophils, bacteria and
cellular debris) causing sinus obstruction.
Sinus pain and pressure: Resulting from
increased intraluminal pressure leading
to facial pain, headache and congestion
Cycle of Stasis and Inflammation
The combination of obstruction, mucus
stasis, and bacterial growth perpetuates
inflammation, worsening symptoms.
If untreated, this can lead to
complications such as orbital cellulitis,
subperiosteal abscess, or intracranial
extension.
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COMPLICATIONS
Chronic Rhinosinusitis: If untreated, ABRS may
transition into chronic sinusitis (symptoms lasting
>12 weeks).
Severe cases:
Orbital complications :
• Orbital cellulitis or abscess.
• subperiosteal abscess
Intracranial complications
• Meningitis, brain abscess (rare)
• Cavernous sinus thrombosis
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• In the first 3 to 4 days of illness, there is difficulty in differentiating a viral etiology from early-
onset bacterial etiology of rhinosinusitis
• Persistence of symptoms for 5 to 10 days,represents the beginning stages of ABRS.
• During this period, a pattern of initial improvement followed by worsening characterized by
new onset of fever, headache or increased nasal discharge may be observed. This pattern of
“double worsening” or “double sickening” is consistent with ABRS.
DIAGNOSIS OF ACUTE BACTERIAL
RHINOSINUSITIS (ABRS)
11. 1.The diagnosis of ABRS is based on the following criteria:
• Acute onset of some or all of the following symptoms: nasal congestion,purulent nasal discharge,
(anterior/posterior nasal drip) with or without facial pain/pressuredental pain and ear
pressure/fullness, fever, cough, fatigue, hyposmia/anosmia that fail to improve after 10 days
• Symptoms worsening within 5-10 days after an initial improvement (i.e. double worsening)
• Symptoms not lasting beyond 4 weeks
Grade D Recommendation, Level 5 Evidence
DIAGNOSING ABRS
12. DIAGNOSING ABRS
2. Physical Examination
• Includes inspection, palpation of maxillary and frontal sinuses, and rhinoscopy.
• Provides information on the chronicity and severity of the patient’s ABRS.
• Nasal decongestion and suctioning of excess secretions may aid diagnosis.
Grade D Recommendation, Level 5 Evidence.
3. Nasal Endoscopy
4. Safe, radiation-free, cost-effective office procedure
• Used to identify purulent discharge, anatomical abnormalities, and collect microbiological samples
through endoscopy guidance
Grade C Recommendation, Level 4 Evidence.
13. 4.Imaging Studies
• NOT recommended for the routine diagnosis of ABRS.
• Reserved for:
• Persistent or recurrent symptoms.
• Suspected complications (e.g., orbital, intracranial, or soft tissue involvement).
• Co-morbidities that predispose to complications, including diabetes, an immune-compromised state, or a
history of facial trauma or surgery.
• CT imaging is preferred for complications or surgical planning.
Grade A(-) Recommendation, Level 1A Evidence
DIAGNOSING ABRS
14. TREATMENT FOR ABRS
1.Primary Treatment: Empiric Antibiotic Therapy
• First-Line Regimen for Low-Risk Patients:
Amoxicillin-Clavulanic Acid: 625 mg every 8 hours or 1 g every 12 hours.
Amoxicillin: 500 mg every 8 hours or 1 g every 12 hours.
Treatment duration: 7-10 days.
Low-risk patients: <65 years, no recent antibiotics (30 days), no hospitalization (5 days), no
co-morbidities, not immunocompromised.
• For Penicillin-Allergic Patients:
Doxycycline 100 mg every 12 hours.
Levofloxacin 500 mg once daily or Moxifloxacin 400 mg once daily.
Macrolides (e.g., erythromycin): Use only where resistance rates are low.
15. 2.Second-Line Antimicrobial Therapy
• Considered for:
High-risk patients of antimicrobial resistance
All patients with worsening or no improvement of symptoms after
5-7 days
• Regimens:
Amoxicillin-Clavulanic Acid 2 g every 12 hours.
Doxycycline 100 mg every 12 hours.
Levofloxacin 500 mg once daily or Moxifloxacin 400 mg once daily.
TREATMENT FOR ABRS
16. TREATMENT FOR ABRS
3.Patients unresponsive to second-line therapy require further evaluation, including:
• CT scan of the Paranasal Sinuses.
• Sinus or middle meatal cultures.
• Immune system studies.
4. Watchful Waiting
• An option for uncomplicated ABRS (e.g., mild symptoms, no extra-sinus
complications).Temperature <38.3 C, no extra-sinus complications), provided that there is
good follow-up
• Start antibiotics if symptoms fail to improve after 7 days or worsen ("double worsening").
Grade A Recommendation, Level 1A Evidence.
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ADJUNCTIVE AND SYMPTOMATIC
TREATMENT
1. Nasal Saline Irrigation (NS)-Hypertonic saline is particularly beneficial
Safe, effective for mucociliary clearance and reducing inflammation.
Grade A Recommendation, Level 1A Evidence.
2. Intranasal Corticosteroid Sprays (INCS)
Effective as monotherapy or combined with antibiotics for symptom relief.
Found to significantly improve symptom resolution.
Topical Nasal Steroids can be used alone or in combination with oral antibiotics
for symptomatic relief of ABRS
Grade A Recommendation, Level 1A Evidence.
18. ADJUNCTIVE AND SYMPTOMATIC
TREATMENT
3.Decongestants/Antihistamines
Lack evidence for efficacy.
Symptomatic management should focus on hydration,
analgesics, antipyretics, saline irrigation and INCS
Grade D Recommendation, Level 5 Evidence.
4.Patient Education
Avoid inciting factors like allergens, irritants, or self-
medication with antibiotics.
Educate on judicious antibiotic use to reduce
antimicrobial resistance
