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8/3/2019 Sinusitis Management.
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DIAGNOSIS AND
MANAGEMENTOF
ACUTE/CHRONICRHINOSINUSITIS
JEAN-PIERRE SOUAID MD, FRCSC
QUEENSWAY-CARLETON HOSPITAL
OTTAWA, ONTARIO
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Rhinosinusitis: Clinical Definition
Rhinosinusitis is defined as:
Inflammation of the nose and the paranasalsinuses characterised by 2 or more symptoms
One symptom should be either nasal
blockage/obstruction/congestion or nasaldischarge (anterior/posterior nasal drip)
.Fokkens et al. Rhinology. 2007;45(suppl 20):1.
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Rhinosinusitis Symptoms
Reduction/loss ofSmell
Facial Pain/pressure
NasalDischarge(anterior/posteriornasal drip)
Blockage/Obstruction/congestion
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Common Cold/Acute Rhinosinusitis
0 5 10 15
Days
Symptom
s
Viral rhinosinusitis/common cold
Acute rhinosinusitis/increase after 5 days
Acute rhinosinusitis/persist after 10 days
No need for antibiotictherapy Consider treatment with antibiotics
and/or steroids
Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 6
RISK FACTORS
EXTRINSIC
INFECTION
ENVIRONMENTMEDICATIONS
FOREIGN OBJECTS
TRAUMA
INTRINSIC
ALLERGY
ANATOMICNASAL POLYPS
TUMOURS
CYSTIC FIBROSIS
CILIARY DYSFUNCTIONIMMUNODEFICIENCY
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 7
PATHOPHYSIOLOGY OF
RHINOSINUSITIS
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 8
MICROBIOLOGY RHINOSINUSITIS
POLYMICROBIAL!!!
S. pneumoniae
40%
M. catarrhalis
20%
S. aureus
6%
S. pyogenes
3%
Other
1%
H. influenzae
30%
ACUTE
CHRONIC ANAEROBES
GRAM NEG.
S. AUREUS
P. AERUGINOSA
Desrosiers et al. J Otolaryngol 2002;31(Suppl 2):2S2-2S14.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 9
Diagnosis: ABS Imaging
X-ray
Air-fluid levels and opacification, when
present, have positive predictive value of
80% to 100%
Sensitivity is low (detects only 60% of sinusitis
patients)
Sensitivity of mucosal thickening is high
(>90% of ABS patients), but nonspecific
The Institute for Clinical Systems Integration. Postgrad Med. 1998;103:154-156, 159-160, 166-168.
http://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdf8/3/2019 Sinusitis Management.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 10
Diagnosis: Cultures
Maxillary sinus puncture and aspiration
Not warranted/recommended
Painful Requires expertise to minimize
complications (eg, infection)
Reserved for research setting or patients
with a complicated infection
Brook I et al.Ann Otol Rhinol Laryngol. 2000;109:2-20.
http://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdf8/3/2019 Sinusitis Management.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 119
Diagnosis of Acute Sinusitis
Symptoms Maxillary / Facial pain
Symptoms >7 days
Dental pain
Poor response todecongestants
History of coloured nasaldischarge
Signs Purulent nasal secretion Abnormal transillumination
Fever
4 or 5 signs orsymptoms
2 or 3 signs orsymptoms
Less than 2
signs orsymptoms
high probability of
sinusitis
Consider radiography
Can rule out sinusitis
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Objectives of Medical Treatment of
Rhinosinusitis
Eliminate infection
Reduce inflammation
Improve symptoms
Multifaceted treatment
regimen
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MFNS as Adjunctive Therapy to Antibiotics?
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Changes in Symptoms Over 21 Days with
Adjunctive MFNS in Acute Recurrent
Rhinosinusitis
*P
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MFNS as Monotherapy?
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0
1
2
3
4
5
6
7
8
9
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
MFNS Monotherapy in Acute
Rhinosinusitis: Effect on Major Symptom
Score
M
ajorsymptomsc
ore
Days
Major Symptom Scores (Days 1-15)
aP0.037 vs placebo.b
P0.012 vs amoxicillin 0.5 g tid.
Adapted from Meltzer et al. J Allergy Clin Immunol. 2005;116:1289.
Data on file, Schering-Plough
MFNS 200 g bid (n=234)
Amoxicillin 0.5 g tid (n=249)
Placebo (n=247)
Baseline
a,ba
a,b
a,ba,b
a,ba,b a,b
a,b a,b a,b a,b a,b
a,b
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid
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Intranasal Corticosteroids:
Low Systemic Bioavailability
There are differences among the various
agents bioavailabilities*
Budesonide (Rhinocort): 20% Triamcinolone (Nasacort): 22%
Fluticasone (Flonase): 2%
Mometasone (Nasonex): < 0.1%
Low bioavailability minimizes risk of
systemic effects*Bioavailability of intranasal triamcinolone and beclomethasone are not reported in product information
Corren J: J Allergy Clin Immunol 1999; 104:S144-9.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid
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TOPICAL STEROIDS
NASONEX AVAMYS OMNARIS
EPISTAXIS 8 % 20 % 6 %
GLAUCOMA NO 2 % NO
KIDS (3 Y.O.) YES YES* NO
POLYPS YES NO NO
ACUTE SINUSITIS YES (bid) NO NO(monotherapy and /or adjuvant)
SEASONAL A.R. YES YES YES
PERENNIAL A.R. YES NO YES
*ONLY FOR PEDIATRIC SEASONAL A.R.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid
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Antibiotic Resistance in ABS
Resistance of ABS pathogens against antibiotics is increasing inCanada
S. pneumoniae:
Up to 20% of isolates are resistant or intermediate to penicillin1
14% are resistant to macrolides2
H. influenzae:3 19% of isolates are resistant to amoxicillin
14% of isolates are resistant to TMP-SMX
M. catarrhalis:3
Resistance levels of isolates are generally low
1.5% resistant to TMP-SMX Fluoroquinolone resistance of respiratory pathogens is low (~1%)
across Canada1,3
1Zhanel et al. AAC 2003;47:1867-74. 2Low et al. CBSN 2003.3Zhanel et al. AAC 2003;47:1875-81.
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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid
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Indications for 2nd-line Antibiotic
Therapy
No clinical response to first-line therapy within48-72 hours
Patients who received antibiotics in previous 3
months (CLASS SWITCHING!) Frontal or sphenoid sinusitis
Allergy to -lactams
Chronic underlying conditions
Immunosuppression
Protracted symptoms
Desrosiers et al. J Otolaryngol 2002;31(Suppl 2):2S2-2S14.
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Statements: SummaryCanadian Rhinosinusitis Guidelines
2011
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf8/3/2019 Sinusitis Management.
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StatementStrength
ofEvidence
Strength ofRecommendati
on
1: ABRS may be diagnosed on clinical grounds using symptoms and signsof more than 7 days duration.
Moderate Strong
2:Determination of symptom severity is useful for the management ofacute sinusitis, and can be based upon the intensity and duration andimpact on patient's quality of life
Option Strong
3:Radiological imaging is not required for the diagnosis of uncomplicated
ABRS. When performed, radiological imaging must always be interpretedin the light of clinical findings as radiographic images cannot differentiateother infections from bacterial infection and changes in radiographicimages can occur in viral URTIs.
Criteria for diagnosis of ABRS are presence of an air/fluid level orcomplete opacification. Mucosal thickening alone is not considereddiagnostic. Three-view plain sinus X-rays remain the standard. Computedtomography (CT) scanning is mainly used to assess potential
complications or where regular sinus X-rays are no longer available.
Radiology should be considered to confirm a diagnosis of ARBS in patientswith multiple recurrent episodes, or to eliminate other causes
Moderate Strong
4: Urgent consultation should be obtained for acute sinusitis withunusually severe symptoms orsystemic toxicity orwhere orbital orintracranial involvement is suspected.
Option Strong
Summary of Guideline Statements: ABRS I
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf8/3/2019 Sinusitis Management.
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StatementStrength
ofEvidence
Strength ofRecommend
ation
5: Routine nasal culture is not recommended for the diagnosis of ABRS.When culture is required for unusual evolution, or when complicationrequires it, sampling must be performed either by maxillary tap orendoscopically-guided culture.
Moderate Strong
6:The 2 main causative infectious bacteria implicated in ABRS areStreptococcus pneumoniae and Haemophilus influenzae.
Strong Strong
7:Antibiotics may be prescribed for ABRS to improve rates of resolution
at 14 days and should be considered where either quality of life orproductivity present as issues, or in individuals with severe sinusitis orcomorbidities. In individuals with mild or moderate symptoms of ABRS, ifquality of life is not an issue and neither severity criterion norcomorbidities exist, antibiotic therapy can be withheld.
Moderate Moderate
8: When antibiotic therapy is selected, amoxicillin is the first-linerecommendation in treatment of ABRS. In beta-lactam allergic patients,trimethoprim-sulfamethoxazole (TMP/SMX) combinations or a macrolideantibiotic may be substituted.
Option Strong
9: Second-line therapy using amoxicillin/clavulanic acid combinations orquinolones with enhanced gram positive activity should be used inpatients where risk of bacterial resistance is high, or where consequencesof failure of therapy are greatest, as well as in those not responding tofirst-line therapy. A careful history to assess likelihood of resistance shouldbe obtained, and should include exposure to antibiotics in the prior 3months, exposure to daycare, and chronic symptoms.
Option Strong
10:Bacterial resistance should be considered when selecting therapy. Strong Strong
Statements ABRS: II
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf8/3/2019 Sinusitis Management.
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StatementStrength
ofEvidence
Strength ofRecommend
ation
11: When antibiotics are prescribed, duration of treatment should be 5 to10 days as recommended by product monographs. Ultra-short treatmentdurations are not currently recommended by this group.
Strong Moderate
12:Topical intranasal corticosteroids (INCS) can be useful as sole therapyof mild-to-moderate ABRS.
Moderate Strong
13:Treatment failure should be considered when patients fail to respond
to initial therapy within 72 hours of administration. If failure occursfollowing use of INCS as monotherapy, antibacterial therapy should beadministered. If failure occurs following antibiotic administration, it maybe due to lack of sensitivity to, or bacterial resistance to, the antibiotic,and the antibiotic class should be changed.
Option Strong
14:Adjunct therapy should be prescribed in individuals with ABRS. Option Strong
15:Topical INCS may help improve resolution rates and improve
symptoms when prescribed with an antibiotic.
Moderate Strong
16: Analgesics (acetaminophen or non-steroidal anti-inflammatoryagents) may provide symptom relief.
Moderate Strong
17:Oral decongestants may provide symptom relief. Option Moderate
18:Topical decongestants may provide symptom relief. Option Moderate
19:Saline irrigationmay provide symptom relief. Option Strong
Statements ABRS: III
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf8/3/2019 Sinusitis Management.
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StatementStrength
ofEvidence
Strength ofRecommend
ation
20: For those not responding to a second course of therapy,chronicity should be considered and the patient referred to aspecialist. If waiting time for specialty referral or CT exceeds 6weeks, CT should be ordered and empiric therapy for CRSadministered. Repeated bouts of acute uncomplicated sinusitisclearing between episodes require only investigation and
referral, with a possible trial of INCS. Persistent symptoms ofgreater than mild-to-moderate symptom severity shouldprompt urgent referral.
Option Moderate
21: By reducing transmission of respiratory viruses, handwashing can reduce the incidence of viral and bacterial sinusitis.Vaccines and prophylactic antibiotic therapy are of no benefit.
Moderate Strong
22: Allergy testing or in-depth assessment of immune functionis not required for isolated episodes but may be of benefit inidentifying contributing factors in individuals with recurrentepisodes or chronic symptoms of rhinosinusitis.
Moderate Strong
Statements ABRS: IV
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Management of ABRS (I)
Recurrent ABRSRepeated symptomatic episodes of acute sinusitis( 4 infections per year), with clear, symptom-freeperiods in between corresponding to completeresolution between infections.Episodes of sinusitis will increase as exposure toviruses increases.
With multiple recurrent episodes, considerradiology (standard 3-vew sinus X-ray or CT scan)
to confirm ABRS or to eliminate other causes
Symptoms of Sinusitis
More than 7 days Less than 7 days
Higher likelihood ofbacterial infection
Requires confirmationof 2 major symptoms*
ABRS Diagnosis Requires the Presence of at Least 2 Major Symptoms*
Major SymptomsNone Mild
Occasionallimited episode
ModerateSteady symptoms
but easily tolerated
SevereHard to tolerate and mayinterfere with activity or
sleep
P Facial Pain/pressure/fullness
O Nasal Obstruction
D Nasal purulence/discolored postnasal Discharge
S Hyposmia/anosmia (Smell)
*Patient must have: 1) Nasal obstruction OR nasal purulence/discolored postnasal discharge, AND 2) At least 1 other PODS symptom.
Consider ABRS under any one of the following conditions: 1) Worsening after 5 to 7 days (biphasic illness) with similar symptoms; 2)Symptoms persist more than 7 days without improvement; or 3) Presence of purulence for 3 to 4 days with high fever.
Viral URTITreat symptomatically
If symptoms persist,worsen or change
RED FLAGS for Urgent ReferralAltered mental status, headache,systemic toxicity, swelling of the orbitor change in visual acuity, hardneurological findings, or signs ofmeningeal irritationSuspected intracranial complications
Meningitis Intracranial abscess Cavernous sinus thrombosis
Involvement of associated structures Periorbital cellulitis Potts puffy tumor
Refer for expert assessment
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Management of ABRS (II)
Identify level of severity
Mild to moderate Severe
Intranasal corticosteroids (INCS)
Clinical response in 72 hrs?
INCS + antibiotics
If symptoms persist,
worsen or changeYes No
Continue course Consider antibiotics if symptomduration is >7 days
First-line: Amoxicillin. For beta-lactam allergy:TMP/SMX combinations or a macrolide.Second-line: Fluoroquinolones or amoxicillin-clavulanic acid combinations. Use with first-
line failures and in patients at high risk ofbacterial resistance or likely to sufferconsequence of treatment failure due tounderlying systemic disease.
Clinical response in 72 hrs?
Yes No
Continue therapy for full courseduration per product monograph
Use second-line agentor change antibiotic class
Clinical response in 72 hrs?
Yes NoFor symptoms lasting >4 weeks, considerchronic rhinosinusitis (CRS); refer to CRSguidelines or visit www.sinuscanada.com foradditional information.Persistent severe symptoms require prompt
urgent referral.
Minor symptomsHeadache Dental painHalitosis CoughFatigue Ear pain/pressure
Prevention Strategies
Hand washingEducationEnvironmental awareness
Adjunct therapyAnalgesics
DecongestantsSalineINCS
When to referNo response to 2nd-line therapy
Suspected chronicityPersistent severe symptomsRepeated bouts with clearingbetween episodes>3 recurrences per yearImmunocompromised host
Allergic rhinitis evaluation forimmunotherapyAnatomic defects causing obstructionNosocomial infectionAssumed fungal infection/neoplasms
Why wait >7 days?Antibiotics may not be necessary andthere are side effects
Diarrhea Interference with contraception Allergy Yeast infections
Review previous 3-month exposure
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Chronic Rhinosinusitis: New for 2011
Emphasis on role of inflammation in thepathogenesis of CRS
Distinction between CRS with nasal
polyposis (CRSwNP) and CRS without NP(CRSsNP)
Management strategies for the PCP
Indications for referral
Management of the post-surgical patient
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StatementStrength
of
Evidence
Strength ofRecommendati
on23:CRS is diagnosed on clinical grounds but must be confirmed with atleast 1 objective finding on endoscopy or computed tomography (CT) scan.
Weak Strong
24: Visual rhinoscopy assessments are useful in discerning clinical signsand symptoms of CRS.
Moderate Moderate
25:In the few situations when deemed necessary, bacterial cultures inCRS should be performed either via endoscopic culture of the middlemeatus or maxillary tap but not by simple nasal swab.
Option Strong
26:The preferred means of radiological imaging of the sinuses in CRS isthe CT scan, preferably in the coronal view. Imaging should always beinterpreted in the context of clinical symptomatology because there is ahigh false-positive rate.
Moderate Strong
27:CRS is an inflammatory disease of unclear origin where bacterialcolonization may contribute to pathogenesis. The relative roles of initiatingevents, environmental factors, and host susceptibility factors are all
currently unknown.
Weak Moderate
28:Bacteriology of CRS is different from that of ABRS. Moderate Strong
29: Environmental and physiologic factors can predispose to developmentor recurrence of chronic sinus disease. Gastroesophageal reflux disease(GERD) has not been shown to play a role in adults.
Moderate Strong
30:When diagnosis of CRS is suggested by history and objective findings,oral or topical steroids with or without antibiotics should be used formanagement.
Moderate Moderate
Statements CRS: I
Statements CRS: II
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StatementStrength
ofEvidence
Strength ofRecommenda
tion
31:Many adjunct therapies commonly used in CRS have limited evidence to
support their use. Saline irrigation is an approach that has consistentevidence of benefiting symptoms of CRS.
Moderate Moderate
32: Use of mucolytics is an approach that may benefit symptoms of CRS. Option Moderate
33: Use of antihistamines is an approach that may benefit symptoms of CRS. Option Weak
34: Use of decongestants is an approach that may benefit symptoms of CRS. Option Weak
35: Use of leukotriene modifiers is an approach that may benefit symptoms
of CRS.
Weak Weak
36: Failure of response should lead to consideration of other possiblecontributing diagnoses such as migraine or temporomandibular jointdysfunction (TMD).
Option Moderate
37:Surgery is beneficial and indicated for individuals failing medicaltreatment.
Weak Moderate
38: Continued use of medical therapy post-surgery is key to success and is
required for all patients. Evidence remains limited.
Moderate Moderate
39 Part A: Patients should be referred by their primary care physician whenfailing 1 or more courses of maximal medical therapy or for more than 3sinus infections per year.
Weak Moderate
39 Part B: Urgent consultation with the otolaryngologist should be obtainedfor individuals with severe symptoms of pain or swelling of the sinus areas orin immunosuppressed patients.
Weak Strong
Statements CRS: II
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StatementStrength
ofEvidence
Strength ofRecommend
ation
40:Allergy testing is recommended for individuals with CRS aspotential allergens may be in their environment.
Option Moderate
41: Assessment of immune function is not required inuncomplicated cases.
Weak Strong
42:Prevention measures should be discussed with patients. Weak Strong
Statements CRS: III
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CRS: Subtypes
CRSwNP Characterized by
Mucopurlent drainage
Nasal obstruction
Hyposmia Diagnosis requires
At least 2 major symptoms
Bilateral polyps in themiddle meatus (endoscopy)
Bilateral mucosal disease(CT scan)
CRSsNP Characterized by
Mucopurlent drainage
Nasal obstruction
Facial pain / pressure /fullness
Diagnosis requires
At least 2 major symptoms
Inflammation (endoscopy)
Absence of polyps(endoscopy)
Purulence from osteomeatalcomplex (endoscopy) orrhinosinusitis (CT)
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CRS: Specialist Referral
Referral to a specialist is warranted when a patient
Fails 1 course of maximal medical therapy, or
Has > 3 sinus infections/year
URGENT consultation w/otolaryngologist required if patient
Has severe symptoms of pain/swelling of the sinus areas, or
Is immunosuppressed
Allergy testing
Identify allergic components that might respond to allergytreatment (e.g., avoiding environmental triggers, or takingappropriate pharmacotherapy or immunotherapy)
Immune function testing
Not required in uncomplicated cases
May be appropriate for patients with resistant CRS
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CRS: Initial Management Is Medical
In the absence of complication or severe illness CRSsNP: nasal or oral corticosteroid and oral
antibiotics
CRSwNP: topical intranasal steroids and shortcourses of oral steroids
Simultaneous oral antibiotic therapy indicatedonly in the presence of symptoms suggestinginfection (eg, pain or recurrent episodes of
sinusitis, or when purulence is documented onrhinoscopy/endoscopy)
M f CRS (I)
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Management of CRS (I)
Obtain CT or perform endoscopy
CRSsNP: 2 major symptoms plus all of the followingEndoscopeInflammation (eg, discolored mucus, edema of middle meatus /ethmoid areaAbsence if polyps in middle meatusPurulence originating from the ostiomeatal complexorCT image
Rhinosinusitis
CRS Diagnosis Requires the Presence of at Least 2 MajorSymptoms*
Major SymptomsNone Mild
Occasional limitedepisode
ModerateSteady
symptomsbut easilytolerated
SevereHard to tolerate
and mayinterfere with
activity or sleep
CFacial Congestion/fullness
PFacial Pain/pressure/fullness
ONasal Obstruction/blockageDPurulent anterior/posterior nasal
Drainage
SHyposmia/anosmia (Smell)
*A diagnosis requires at least 2 CPODS, present for 8 to 12 weeks, plusdocumented inflammation of the paranasal sinuses or nasal mucosa.
CRS is diagnosed on clinical grounds but must be confirmed with at least 1 objective finding onendoscopy or CT scan.
CRSwNP: 2 major symptoms plus all of the followingEndoscopePresence of bilateral polyps in middle meatusCT image
Bilateral mucosal disease
Immediately ReferUrgent consultation forIndividuals with severe painor swelling of the sinus areasor in immuno- compromisedpatientsSuspected invasive fungalsinusitisConsider referral soon
When failing 1 course ofmaximal medical therapyFor 4 sinus infections peryear
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Management of CRS (II)
Reassess after 2 to 4 months
CRSsNP
Persistence or
Recurrence of symptoms
Possible alternative diagnoses Allergic fungal rhinosinusitis Allergic rhinitis Atypical facial pain Invasive fungal rhinosinusitis Migraine or other headache
diagnosis Nasal septal deformation
Nonallergic rhinitis Temporomandibular joint
dysfunction (TMD) Trigeminal neuralgia Vasomotor rhinitis
CRSwNP
If positive exam, treat with INCS Antibiotics (2nd line) Consider short course of oral
steroids Consider saline irrigation
+/- specialty assessment
Clinical improvement after 4 weeks?
Yes No
Continue INCSConsider saline
irrigation
Refer for surgicalevaluation
If negative exam, assumerecurrent sinusitis and treatwith INCS or consideralternative diagnoses
INCS Short course oral steroids Antibiotic if suspicion of infection (purulence or pain)
Broad spectrum such as fluoroquinolones oramoxicillin-clavulanic acid combinations
Consider leukotriene receptor antatgonists in
appropriate patients Specialty referral Allergy testing if suspected allergen present in
environment
Persistent improvement
Refer to surgeonContinue INCS
Consider saline irrigation
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