Adventures in Rhinorrhea A Review of Sinusitis and Common Cold Peter Adler, MD Attending Physician UPMC Passavant 2/12/2015

Adventures in Rhinorrhea

A Review of Sinusitis and Common Cold

Peter Adler, MDAttending Physician UPMC Passavant

2/12/2015

Who Am I?

• Graduated from UPMC EM residency in 2009• Worked at Shadyside from 2009-2013• Worked in North Carolina from 2013-2014• Now work at UPMC Passavant

Purpose of this talk

• Explain typical course of Acute Bacterial Sinusitis (ABS) and Common Cold (CC)

• Explain evidence behind our therapeutic options

• Reduce your internal dread when a patient asks for an inappropriate antibiotic

Patient #1

• 35 y/o male• 3 days of feeling “sick”• C/o sore throat initially– Fever yesterday to 102– Bilateral facial pain and headache– Nonproductive cough

• Rhinorrhea x 1 day, ST improving• AFVSS• Physical exam essentially WNL

Should this patient receive an antibiotic?

1. Yes2. No

1 2

50%50%

Patient #2

• 30 y/o female with 7 days of rhinorrhea– Sore throat on days 1-3, now gone– Fever days 2-4, improved, now fever again x 1 day– No improvement in rhinorrhea• Facial pain is “getting worse”

– More on left than right

• Rhinorrhea is “green-colored”• Now with dental pain

Should you prescribe this patient an antibiotic? (1 of 2)

1. Yes2. No

1 2

50%50%

0 of 30

What first-line antibiotic should you choose (assume NKDA)? (2 of 2)

1. Amoxicillin2. Cefinidir3. Levofloxacin4. Macrodantin5. Linezolid

1 2 3 4 5

20% 20% 20%20%20%

0 of 30

Epidemiology of ABS/CC

• ABS costs $5.8 billion/yr– Including all patients given the diagnosis of

sinusitis– 11-16% of all adults will be diagnosed / yr

• Common cold costs $40 billion/yr– Average kid gets 8-12x/yr– Average adult gets 2-3x/yr

Ray et al. J Allergy and Clinical Immunology, Mar 1999.

What % of all antibiotics prescribed in the US are for sinusitis?

1. 5%2. 10%3. 20%4. 30%

1 2 3 4

25% 25%25%25%

0 of 30

Rhinorrhea Syndromes

• Rhinitis – Involves nasal passages only

• Rhinosinusitis (Sinusitis)– Involves nasal passages and sinuses

• 4 sinuses– Maxillary– Sphenoid– Ethmoid– Frontal

Image from http://ilmukedokterangigi.com/?p=336

dresdenplates.blogspot.com

Pathogenesis of Sinusitis

• Inflammatory response to bacterial/viral/ fungal/allergic challenge– Increased mucus buildup and viscosity– Ciliary paralysis or hypokinesis– Nasal conchae become obstructed and swollen– Mucus stagnates in sinuses– Further infectious contamination leads to primary

or secondary infection

Risk factors

• Allergic rhinitis• Asthma• Nasal obstruction– Polyps– Foreign body– Nasal intubation

• Immunodeficiency• Tobacco smoke• Pollution• GERD?

Definitions of Sinusitis

• Acute– Symptoms less than 4 weeks

• Subacute – 4-8 weeks

• Chronic– More than 8-12 weeks

• Recurrent – 3+ episodes of acute sinusits / yr

Causes of Acute Infectious Sinusitis

• Viral– 98-99.5% estimated

• Bacterial • Fungal– Aspergillus– Candida– Histoplasma– Coccidioides– Cryptococcus

• Allergic*

What’s a cold and what’s bacterial sinusitis?

The $$$$$$$$$$$$$$$$ Question………………………..

http://theallergypage.com/page_18.html

Time Course of URI

• Time to onset 1-3 days after exposure• Total course of illness: 5-14 days– Should be improving by day 7

• Clear->yellow->green phlegm color typical• Green color of sputum DOES NOT EQUAL

BACTERIA– But may be suggestive….like WBC for appendicitis

Uncomplicated URI vs Sinusitis

• Symptoms frequently indistinguishable from bacterial sinusitis on days 1-5!

Clinical Features of Acute Bacterial Sinusitis (ABS) vs Common Cold (CC)

Symptom or Sign Sensitivity Specificity + Likelihood Ratio

Maxillary toothache 18 93 2.5

No improvement with decongestants 41 80 2.1

Purulent secretion 51 76 2.1

Abnormal transillumination 73 54 1.6

Sinus tenderness 48 65 1.4

Cough 70 44 1.3

Sore throat 52 56 1.2

Headache 68 30 1.0

Williams JW et al. Clinical Evaluation for Sinusitis: Making the diagnosis by history and physical examination. Annals of Internal Medicine. 1992; 117:705-710.

Prospective study, n=247 males, gold standard was x-rays, 92% sensitivity if all red-highlighted criteria present

Classical Guidelines for Diagnosis of Acute Bacterial Sinusitis

• Symptoms of Viral URI for >10 days– Or acute worsening after 5-7 days• Unilateral facial pain• Maxillary dental pain• “Moderate to Severe symptoms”• “Double sickening”

http://www.aafp.org/afp/2006/0915/p956.html

“Official Diagnosis” of ABS

• Major criteria – Facial pain/pressure– Purulent nasal discharge– Fever– Nasal congestion– Nasal obstruction– Hyposmia/anosmia

• Minor criteria– Headache– Cough– Fatigue– Halitosis– Dental pain– Ear pressure

*In a patient >7 days of symptoms.**2 major or 1 major and 2 minor criteria.From: Task force on rhinosinusitis: in Haro et al. Sinusitis and Rhinitis. Harwood Nuss’ Clinical Practice of Emergency Medicine, 2005

My Strategy…….. ABS if:

• Days 1-5– Fever, unilateral sinus tenderness, maxillary pain,

purulent discharge (if early)• Consider delayed Abx script to start day 5-7 if trustworthy

• Days 6-14ish– Abx if patient got better and then worsened– If above symptoms present and not improving

• More than 2/3 weeks– Not ABS…..consider recurrent ABS or chronic

Of course…………

• There are some patients who you can’t convince they have a virus

• Try and educate but know when to quit– Kids are exception

http://www.gponline.com/consultation-skills-staying-calm-angry-patients/article/1051676

Diagnostic tests

• Imaging?– X-ray– CT– MRI

• Rhinorrhea culture– Typically contaminated– Reserved for refractory sinusitis • Done by trained ENT, not us

Imaging

• Xrays– AP view (Caldwell)– Occipitomental 4-view (Waters)– Complete sinus opacification– Mucosal thickening >4mm– Air fluid level

• CT – mucosal thickening• Ultrasound?– “back wall echo”

Ghorayeb.com

Imaging

• X-rays– Poor specificity and sensitivity– No longer routinely used

• CT– Test of choice but…..

• Mucosal thickening seen in 40% of asymptomatic patients

– Best test to evaluate for sinusitis complications• MRV– Test of choice to rule out Cavernous sinus thrombosis

Cavernous Sinus Thrombosis

http://doctorspiller.com/cavernoussinus.htm

Complications

• Periorbital/orbital cellulitis/abscess• Meningitis• Cavernous sinus thrombosis• Epidural/subdural empyema• Brain abscess• Maxillary sinusitis as a complication of dental

abscess

Chronic Sinusitis

• Greater than 8 weeks of symptoms• Nasal steroids have shown benefit• Antihistamines helpful• Oral steroids also possibly beneficial but

studies mixed– Seems more useful if nasal polyps present

• Saline irrigation also helpful– Not well-studied in acute sinusitis

Treatment of ABS/URI

• Antibiotics?– Do we need them?– Which ones?– How long?

• H1 antagonists?• Alpha agonists?• Nasal Saline?• Vitamin C?• Zinc?

You diagnose ABS. What is the role of an antibiotic in your management?

1. None, you don’t need to give one

2. Patient will get better anyway, just faster with abx

3. The disease will spread or not improve w/o abx

1 2 3

33% 33%33%

Are antibiotics necessary at all?

• Let’s look at the data.......

Abx vs Placebo at 7-15d

Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2

From: Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and Neck Surgery. 137, S1-S31. 2007.

Conclusions: Abx for ABS

• Antibiotics seem to decrease time to cure– Avg. 12 days with placebo– Avg. 8 days with antibioitic– No change at 2 weeks

• No change in complication rates in immunocompetent patients

• Adverse side effects (RR=1.75, ARR=0.11)– Diarrhea– GI upset– Allergic reactionAhovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M.

Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2

Duration of antibiotic

• Classical teaching = 10 days– Allows for extra time for antibiotic to penetrate

nasal mucosa and into mucus

• Meta-analysis………

Falagas et al. Effectiveness and safety, etc. British Journal of Clinical Pharmacology. 2008. 67:2, 161-171

Meta-analysis of clinical success for short course (3-7 days) vs. long course (7-14 days)

Adapted from: Falagas et al. Effectiveness and safety, etc. British Journal of Clinical Pharmacology. 2008. 67:2, 161-171

Conclusion

• Duration from 3-14 days doesn’t seem to matter

• Studies indicate 7 day course may give optimal treatment

So antibiotics may be somewhat helpful….which one(s) should I use?

Which antibiotic should NOT be used for first-line therapy

1. Azithromycin2. TMP/SMX3. Amoxicillin4. Moxifloxacin5. Clarithromycin

1 2 3 4 5

20% 20% 20%20%20%

Bacteria in SinusitisOrganism % isolates/ Adults % isolates / Children

Streptococcus pneumoniae 41 41

Haemophilus influenzae 35 27

Anaerobes 7 0

Streptococcal species 7 7

Moraxella catarrhalis 4 22

Staphylococcus aureus 3 0

Other 4 4

Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed. 2009. “Sinuisitis”

First line antibiotics

• Amoxicillin– Amoxicillin/Clavulanate?

• Bactrim• If allergic:– Azithromycin– Clarithromycin

Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and Neck Surgery. 137, S1-S31. 2007.

Second line antibiotics

• Use if patient failed a 1st line antibiotic in past month– Wait at least 7 days before diagnosing treatment

failure*– Amoxicillin/Clavulanate– Quinolones– Doxycycline– 2nd/3rd generation cephalosporins

Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and Neck Surgery. 137, S1-S31. 2007.

Antibiotics for Common Cold (CC)

• Cochrane Review 2013; abx vs placebo for CC– Pooled RR of .95; (95%CI 0.59-1.51); N=1047– RR of 2.62 (95%CI 1.32-3.21) for side effects with

antibiotics– “Routine use of antibiotics for common cold not

recommended”

Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD000247. DOI: 10.1002/14651858.CD000247.pub3.

Non-antibiotic therapies

• Will focus on CC, but most therapies hold for ABS as well……..

Treatment options for Common Cold (CC) and adjuncts to ABS therapy

• NSAIDs• Antihistamines• Decongestants• Complementary and Alternative Medicine (CAM) options

– Echinacea– Garlic– Vitamin C– Zinc– Steam

• Ipratropium IN• Others

NSAIDs for CC

• 9 RCTs, n=1069– No significant change in symptom score– No significant change in CC length– No significant change in cough, rhinorrhea

• Significant benefit in headache, ear pain, myalgias (as expected)– Significant benefit in sneezing– OR 2.94 (95%CI 0.51-17.03….2 studies) for side

effectsKim SY, Chang YJ, Cho HM, Hwang YW, Moon YS. Non-steroidal anti-inflammatory drugs for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006362. DOI: 10.1002/14651858.CD006362.pub3.

Analgesics for cough• DCRCT in 1992, n=79 with CC, Naproxen vs placebo– 29% reduction in 5 day symptom score (95%CI 16-42%)– Pooled symptoms include headache, myalgia, malaise,

and cough– Some texts will cite this study to say Naproxen is good

for cough• No good data on NSAIDs for cough• CR: No good data on codeine or opioids for

cough/congestion

Sperber SJ, Hendley JO, Hayden FG, Riker DK, Sorrentino JV, Gwaltney JM. Effects of Naproxen on Experimental Rhinovirus Colds: A Randomized, Double-Blind, Controlled Trial. Ann Intern Med. 1992;117:37-41.

Antihistamines for CC/ABS

• Monotherapy provides no benefit at any age (12 trials as of 2003, 1 showed marginal benefit)

• Side effects of dry mouth, thicker nasal mucus• 2nd generation antihistamines also ineffective in

monotherapy• Last review from 2003, multiple endpoints

De Sutter AIM, Lemiengre M, Campbell H. Antihistamines for the common cold. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD001267. DOI: 10.1002/14651858.CD001267.

Decongestants

• Pseudoephedrine– Behind counter, limited availability

• Phenylephrine– Similar to, but weaker than, pseudoephedrine

• Oxymetazoline (aka Afrin)– IN only

• All are alpha-agonists– Cause vasoconstriction to nasal mucosa

Oxymetazoline (Afrin) IN

• No Cochrane review, looked at PubMed• German trial 2005, n=247, Afrin vs placebo– Duration of rhinitis decrease from 6->4 days– 84% treatment arm vs 44% placebo arm reported

“very good” reduction of symptoms– Effect most pronounced on day 2

• Surprisingly that’s all I could find for placebo controlled trials for non-allergic rhinitis!

• Rhinitis medicamentosa….3 days only for spray

Oral decongestants Alone• 6 studies, n=643, (MD -.24)– 2 studies with benefit, 4 without– Benefit marginal at best

• Side effects (OR 1.43): – HTN, insomnia, headache

Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001953. DOI: 10.1002/14651858.CD001953.pub3.

Antihistamine-Decongestant Combos

• Not helpful by themselves, but when their effects combine……..

Antihistamine-Decongestant combos

• Pooled data on 6 trials, n=309– For severity of symptoms OR 0.27 (95%CI 0.15-0.50)

• NNT=4.4 (95%CI 3-5.6)

• Studies in adults and “older children” only– No similar effects in young children

• Side effects (OR 1.58)– Dry mouth– Somnolence– Dizziness– Hypertension


Antihistamine-Decongestant Severity

De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestant-analgesic combinations for the common cold. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD004976. DOI: 10.1002/14651858.CD004976.pub3.

Antihistamine-Decongestant Side Effects

De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestant-analgesic combinations for the common cold. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD004976. DOI: 10.1002/14651858.CD004976.pub3.

Antihistamine/Decongestant combo

• Actually works!• Side effects (OR 1.58)– Dry mouth– Somnolence– Dizziness– Hypertension


Ipratropium Bromide (Atrovent) IN

• Cochrane Review (CR) 2013– Metaanalysis of 7 trials, n=2144, all adults– Can improve rhinorrhea by 15% on average– No effect on “nasal stuffiness”– Side effect profile (OR 2.09)• Epistaxis• Nasal dryness

– No studies I could find on nebulized Atrovent

AlBalawi ZH, Othman SS, AlFaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD008231. DOI: 10.1002/14651858.CD008231.pub3.

Complementary and Alternative Medicine (CAM) Options

• Echinacea• Garlic• Steam• Honey• Vitamin C• Zinc• Will focus on illness incidence, severity, and

duration– Ratio of efficacy to side effects important

Echinacea vs Placebo for CC: Incidence

Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub3.

People dropping out of Echinacea trials due to side effects


Echinacea vs placebo for CC: Severity


Echinacea• 24 DBRCTs, n=4631– 12 trials on prevention……most showed some benefit– Post hoc pooling of data showed 10-20% RRR

• 2 trials on CC (common cold) cure showed no benefit for therapeutics

• Many people drop out of trial due to side effects– 7% have allergic rash, rare anaphylaxis

• CR authors: Not recommended at this time– Never for kids<12


Herbals/CAM

• Garlic– 1 trial met inclusion criteria for Cochrane, n=146– Prevention trial for 12 weeks– 24 got CC in tx arm, 65 in placebo– No reliable treatment trials

Lissiman E, Bhasale AL, Cohen M. Garlic for the common cold. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD006206. DOI: 10.1002/14651858.CD006206.pub4.

Steam

• Warm, Humidifed air– 6 trials, n=394– Overall symptom relief for CC; OR 0.31 (95%CI

0.16-.60)• No change when specific symptoms evaluated directly

– No change in viral shedding– Minor side effects– CR authors: No enough data to recommendSingh M, Singh M. Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001728. DOI: 10.1002/14651858.CD001728.pub5.

Nasal Saline

• No good trials– CR: No evidence to give recommendation

• I recommend it because there is essentially no risk and it’s something we can do

Vapor Rub

• (1 study, n=138) shows Likert scale change of 1 for multiple markers compared to placebo– 12/44 “skin burning” side effects– Marginal benefit in all markers EXCEPT rhinorrhea

Honey for cough

• Study in 2007, DBRCT, kids age 2-18, n=105, 3 tx arms (honey, DM, placebo), patients with URI– No improvement in DM arm– Average around 1 point Likert scale improvement

with honey

Ian M. Paul, MD, MSc; Jessica Beiler, MPH; Amyee McMonagle, RN; Michele L. Shaffer, PhD; Laura Duda, MD; Cheston M. Berlin Jr, MDEffect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and Their ParentsArch Pediatr Adolesc Med. 2007;161(12):1140-1146. doi:10.1001/archpedi.161.12.1140.

Honey

• Honey (particularly Buckwheat) for cough– Cochrane review based on 2 studies, n=154– 1-2 tsp PO qhs– No effect on rhinorrhea– Significant effect on cough, better sleep for child

and parent

Honey vs Placebo for cough in kids

Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub4.

Vitamin C

• 29 RCTs, N=11306 (!) for prevention/incidence– Pooled RRR of 0.97% (95%CI 0.94-1.00)• May be better for those doing distance training in cold

weather…… RRR of 0.48

• 31 RCTs on cold duration, n=9745– Adult duration decreased 8% (95%CI 3-12%)– Children’s duration decreased 14% (95%CI 7-21%)

Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub4.

*Note the following 3 slides were also taken from this article

Incidence; Taking chronically

Incidence: Taking chronically, exposed to physical stress/cold

Duration; Taking Vit C chronically; adults

Duration; Taking Vit C chronically; children

Severity: Taking Vitamin C Chronically

Duration: Taking Vitamin C when sick

Severity: Taking vitamin C when sick


Vitamin C Conclusions

• Vitamin C works well, if taken chronically, to decrease severity and duration of colds, but not their incidence

• May work slightly better in kids• Data less clear if you start it when sick• Few side effects• Cochrane authors: CC patients should test on an

individual basis whether or not to take Vitamin C

Vitamin C caveats

• For some reason, better in really cold climates– Canadian studies show more benefit than

American• Also better in times of severe physical stress– Trying to mitigate your cold before a sporting

event• May not be generalizable to our population


Zinc

• Comes in many forms– Losenge, tablet, nasal spray, etc.

• 16 treatment trials n=1387• 2 prevention trials n=394

Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.

Zinc vs Placebo: Incidence


Zinc vs placebo: duration


Zinc vs Placebo: Severity


Zinc

• Marginal effect on Duration of symptoms– Average of -1.03 days (95%CI -1.72 to -0.34)– Studies about 50-50 as to showing benefit at all

• Trend toward improvement of severity, but not significant

• Incidence is lower if taken chronically RRR 0.64 (95%CI 0.47-0.88)– Based on 2 small studies


Zinc

• Side effects OR 1.58 (95%CI 1.19-2.09)– Most benign (GI, etc.)

• 2 major effects– Disrupts copper metabolism-> can lead to

elevated saturated fat levels– Can cause permanent anosmia (FDA warning,

2009)• More common in intranasal form (DO NOT USE)


Zinc Conclusions• 50/50 chance will decrease CC duration by

average of 1 day • Non-significant trend towards decreased

severity of CC symptoms• Must take within 24 hours of symptom onset

to have effect• Take >75mg/day for full effect


A Comment about Dextromethorphan and Guaifenesin

• Most trials on these are industry sponsored• CR: No clear evidence one way or another• UTD: Common cough medicine ingredients include

guaifenesin and dextromethorphan; these are often combined with other medications in over-the-counter cold formulas. However, the benefit of cough medicines is likely to be small to non-existent. In clinical trials, cough suppressants were no more effective in reducing the duration or severity of coughing due to cold than a placebo (a non-drug substitute).

• Translation: they may work but have not been proven

Sexton et al. Patient information: The common cold in adults (Beyond the Basics). http://www.uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics. Jan 2015

http://www.uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics

http://www.uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics

Things that DON’T work for CC treatment in adults

• Steam• Vitamin E• Oral Steroids• Antibiotics• Antihistamine monotherapy• Codeine• Albuterol (unless wheezing)• Nasal Steroids• Nasal irrigation (1 RCT, therapeutics only)• Vitamin C• Dextromethorphan (mixed outcomes…..cough only)• Guaifenesin (mixed outcomes….cough only)

Things that MAY work in CC in adults

• Ipratropium Bromide– IN (well-studied) or inhaled/NEB (not well studied)

• NSAIDs– Only for pain/fever symptoms

• Decongestants alone (marginal)– Topical seems ok for 3 days

• Zinc (may decrease duration by 1 day)– Take 75mg/day within 24 hours for 5 days

• Vitamin C – Better in certain subgroups

Things that DO work in CC in adults

• Antihistamine/decongestant combos– NNT=4.4– Caution side effects• HTN• Rhinitis medicamentosa with oxymetazoline

Important Information about kids

• They are not little adults…….– When it comes to cold meds

• Any kid under 4 should not be given any OTC oral med for cough/cold– Exception: NSAIDs/Tylenol– Honey ok for age>1yr– Some studies indicate<age 6

Things that don’t work for kids to treat CC/ABS

• Fluids• Antibiotics• Dextromethorphan• Antihistamines• Decongestants• Antihistamine/decongestant combos• All Steroids (unless asthmatic/wheezing)• Echinacea• All OTC AntitussivesJULIA FASHNER, MD; KEVIN ERICSON, MD; and SARAH WERNER, DO.

Treatment of the Common Cold in Children and Adults. Am Fam Physician. 2012 Jul 15;86(2):153-159.

Things that MAY work in kids

• Saline irrigation/nasal spray– No good studies on therapeutics

• NSAIDs– For pain and fever

• Ipratropium bromide IN– Not well studied in kids, beneficial in adults

• Zinc– 14% severity improvement in kids vs 8% improvement in adults

if taken within 24 hours• Honey – 1-2tsp qhs for 3-5 days• Vapor Rub – one application

What I would have said before this talk (adults and kids)

• Suck it up• Drink plenty of fluids• Nasal saline PRN• 7-10 days to get better– 10-14 days for bronchitis

• OTC meds don’t work

What I will offer now (adults)

• Antibiotic for ABS only if diagnosis highly suggestive• If you feel the need to give something for CC– Antihistamine/decongestant combo if not

contraindicated• Or Afrin IN for 3 days

– NSAIDs for pain or fever• If you feel the need to do more– Ipratropium bromide IN for rhinorrhea– Nasal Saline– Zinc lozenge if for 5 days if sx <24hours

What I will offer now (kids>4)

• ABS is rare, abx only if highly suggestive• If you feel the need to do something for CC– NSAIDs for pain/fever– Buckwheat honey (2 tsp qhs)– Saline nasal spray

• If you feel the need to do more– Ipratropium bromide IN for rhonorrhea– Zinc lozenges for 5 days (if presenting within 24

hours)

What I will offer now (kids<4)

• ABS basically nonexistent• Bulb suctioning +/- nasal saline• NSAIDs for fever• If you feel the need to do something:– Honey (if age>1)

• If you feel the need to do more:– No recommendations

Overall conclusions

• 98-99.5% of acute infectious rhinorrhea is viral• A common cold getting worse after day 5 may

be acute bacterial sinusitis• Be specific with use and choice of antibiotic– Patient may be better 4 days faster with correct

abx if correct diagnosis of bacterial sinusitis made• Consider use of adjunctive therapy– Especially antihistamine-decongestant combos

References

• Ray NF et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J of Allergy and Clinical Immunology, 1999 March; 103: 408-14.

• http://www.aafp.org/afp/2006/0915/p956.html• Falagas et al. Effectiveness and safety, etc. British Journal of

Clinical Pharmacology. 2008. 67:2, 161-171• Williams JW et al. Clinical Evaluation for Sinusitis: Making the

diagnosis by history and physical examination. Annals of Internal Medicine. 1992; 117:705-710.

• Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed. 2009. “Sinuisitis”

http://www.aafp.org/afp/2006/0915/p956.html

References

• Varonen et al. Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Journal of Clinical Epidemiology. 53: 940-948. 2000

• Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and Neck Surgery. 137, S1-S31. 2007.

• Williams et al. Does this Patient have Acute Sinusitis? JAMA 270;10. 1242-46. 1993.

• Leung RS, Katial R. The Diagnosis and Management of Acute Sinusitis. Primary Care: Clinics in Office Practice. 35:11-24. 2008.

References• Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW,

Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2

• Marx et al. Sinusitis. Rosen’s Emergency Medicine. (online) 2011

References

• The rest are scattered throughout the talk and cited accordingly

Documents

Adventures in Rhinorrhea A Review of Sinusitis and Common Cold Peter Adler, MD Attending Physician UPMC Passavant 2/12/2015