ACUTE RHINOSINUSITIS
HUNTER A. HOOVER, M.D.
CHARLOTTEEYEEAR NOSE AND THROAT ASSOCIATES, P.A.
Viral Rhinosinusitis the common cold
1. History
(a) Duration of symptoms
improving (but not necessarily resolved) after 7-10 days
(b) Pattern of symptoms
initially, sore throat (with fever and myalgia)
then, nasal symptoms (may have purulence for a few days)
finally, cough (which usually lasts weeks)
2. Treatment
(a) Antihistamines
first generation antihistamines help
because of their anticholinergic activity
alkylamines produce the least sedation and most anticholinergic activity
ex: chlorpheniramine and brompheniramine
majority of OTC meds contain chlorpheniramine
ex: Chlor-Trimeton, Comtrex, Contac, Pediacare
antihistamines in tannate form are dosed BID, even in suspension form
ex. chlorpheniramine tannate (with phenylephrine tannate) in Rynatan susp.
(b) Methscopolamine nitrate
antisecretory agent, so causes drying of secretions
including saliva
does not significantly cross blood brain barrier
so sedation is unlikely
may be combined with:
decongestant (ex. AlleRx-D)
decongestant in morning and antihistamine/decongestant in evening
(AlleRx Dose Pack & AlleRx-PE Dose Pack…available in 10 & 30 day packs)
antihistamine (ex. AlleRx DF Dose Pack)
antihistamine/decongestant (ex. Dallergy)
(c) Anticholinergic spray
Atrovent 0.06% indicated for rhinorrhea of colds
in adults and children 6 years and up
(d) Oral decongestants
pseudoephedrine is probably superior to phenylephrine
pseudoephedrine tannate and phenylephrine tannate are dosed BID, even in suspension
does not seem to worsen controlled hypertension
(e) Topical decongestants
in adults, oxymetazoline (Afrin) BID or phenylephrine (Neo-Synephrine) QID
in children 2-6 years old, consider prescription for tetrahydrozoline (Tyzine) QID
or, in select cases, diluted Afrin
more effective with less side effects than oral decongestants
must emphasize need to limit duration of use to 5 days or less
(f) Expectorants
unlikely benefit, since secretions typically not thick
(g) Antitussives
limited benefit
(h) Combination products
antihistamine/decongestant combinations seem to have the most benefit
Ryna-12 is a liquid combination dosed b.i.d.
must weigh benefit against side effects (sedation, insomnia, urinary retention, etc.)
(i) Zinc gluconate lozenges
theoretic mechanism of action is local, not systemic
dissolve one lozenge in mouth every 2 hours while awake beginning within 24
hours of onset of cold
high incidence of nausea and bad taste
conflicting studies as to effectiveness
(j)Zinc nasal swabs and spray
marketed as Zicam cold remedy swabs and spray
removed from market due to FDA concerns
regarding possible loss of sense of smell
(k) No antibiotics
antibiotics have only a small chance of be beneficial
in adults, only 1% of colds become bacterial sinusitis
in children, only 0.5-5% of colds become bacterial sinusitis
the small chance of preventing a bacterial infection must be weighed against
increased incidence of developing resistant bacteria
potential side effects of the antibiotic
studies substantiate that patient satisfaction can be achieved without prescribing antibiotics
Acute Bacterial Rhinosinusitis
1. History
Factors to consider:
(a) duration of symptoms
lasting at least 7-10 days
(b) persistency of symptoms
not improving after 7-10 days
(c) pattern of symptoms
worsening of symptoms after initial improvement (i.e “double sickening”)
(d)type of symptoms
persistent purulent nasal discharge
facial pain/pressure
especially localized facial pain and/or maxillary teeth pain
nasal obstruction
fever beyond the first few days
Diagnostic guidelines (Otol-HNS 2007;137:S1-S31)
(a) symptoms persisting more than 10 days and including:
- purulent nasal discharge, and
- nasal obstruction, or facial pain
(b) symptoms worsening after initial improvement (i.e “double sickening”)
even if less than 10 days
2. Physical Exam
(a) Anterior rhinoscopy
pus in the nasal cavity is supportive, but not conclusive, for bacterial infection
purulent drainage may also be seen in oropharynx
(b) Percussion (i.e. tap tenderness)
not helpful, unless definitely abnormal
(c) Transillumination
in adults, helpful if done with proper technique and if definitely normal or abnormal
in children, no proven benefit
(d) Nasal endoscopy
helpful but requires expertise, special equipment, and patient cooperation
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3. X-Ray
(a) Plain films
correspond to maxillary sinus aspirate in only 70% of cases
findings of “air-fluid level” and “maxillary opacification” are relatively specific for bacterial maxillary sinusitis
including the finding of “mucosal thickening” increases the sensitivity, but
decreases the specificity of plain films
the absence of all three of these x-ray findings strongly suggests against
bacterial maxillary sinusitis
extremely poor in evaluating the ethmoid sinuses
a normal plain film may rule out maxillary sinusitis, but not ethmoid sinusitis
(b) CT
“gold standard” for detecting inflammation, but not necessarily a bacterial infection
90% of viral infections have abnormal mucosal thickening on a sinus CT
30% of reportedly asymptomatic patients have abnormal findings on a sinus CT
4. Antibiotic Treatment
(a) Need for antibiotics
spontaneous resolution rate of clinically determined sinusitis is around 66%
benefits of antibiotic:
more rapid resolution of symptoms
50% reduction in clinical failures
recent position paper (Otol-HNS 2007; 137:S1-S31) endorsed watchful waiting as an
option (not recommendation) if:
mild illness
assurance of follow-up
(b) Choice of antibiotics
first line:
pediatric…amoxicillin 80 mg/kg/day divided BID
take child’s weight in pounds
double it
add a zero
give that dose BID
adult…amoxicillin 500 mg three tablets BID
second line (in order of efficacy):
Avelox / Levaquin
Augmentin XR and ES
Augmentin 875
Vantin / Omnicef / Ceftin
(c) Duration of antibiotics
short course therapy of 5 days may be adequate for most routine cases
as supported by “double tap studies”
more prolonged courses may be warranted for chronic and/or recurrent cases
5. Adjunctive Treatment
(a) Topical decongestant
refer to “Viral Rhinosinusitis” section
(b) Oral decongestant
refer to “Viral Rhinosinusitis” section
(c) Antihistamine
usually not necessary because most cases of sinusitis follow a “cold”, not allergies
if used, select a second generation one to avoid anti-cholinergic drying effects
unlike colds where first generation antihistamines should be used
(d) Expectorant
for guaifenesin to be effective, need maximum dosing
2-6 years old……total daily dose of 600 mg
6-12 years old..…total daily dose of 1200 mg
12 years and up…total daily dose of 2400 mg
products that provide 2400 mg for a day
Robitussin (guaifenesin 100 mg/5 cc) 30 cc QID
Mucinex (guaifenesin 600 mg) 2 tabs BID
generic guaifenesin tabs (400 mg) 2 tabs TID
immediate release and least expensive
(e) Saline wash
instead of 1-2 sprays, “wash” with
multiple squirts from OTC nasal spray container
lavage bottle (ex.
neti pot
commercial canisters which “wash”
Simply Saline (available at most drugstores)…either normal or hypertonic saline
ENTsol spray (available at saline
can make hypertonic saline, by adding
1 heaping teaspoon of Kosher or canning/pickling salt
plus a pinch of baking soda
into 8 ounces of distilled water
(f) Topical nasal steroid sprays
appear safe to use even in the presence of a bacterial infection
Cochrane review in 2007 supports their use
(g) Oral steroids
a consideration for:
severe sinusitis with impending complication
persisting sinusitis despite appropriate antibiotic treatment
most physiologic to use orally only once a day in the morning
taper is probably not necessary if steroid course is 10 days or less
Allergic Rhinitis
1. History
-distinction from viral rhinitis:
-fever and other systemic symptoms suggest against allergy
-itching of nose and eyes are suggestive of allergy
-allergy symptoms are chronic
often lasting longer than 7-10 days
-allergy symptoms are recurrent
often in a predictable pattern based on change in environment
“frequent colds” may be allergic rhinitis
-correlation with allergy testing
-results of allergy tests need to be consistent with timing of symptoms
2. Avoidance
-if symptoms worse during pollen seasons
-keep windows closed and allow AC to filter out the pollens
-if symptoms are perennial (i.e. possible dust mite allergy)
-use pillow and mattress mite-proof encasings
-use a vacuum with HEPA filtration or special allergy bags on a weekly basis
-keep humidity less than 50%
-exterminate any cockroaches
-if symptoms worse with animal exposure
-ideally, get rid of offending pet
-more realistically, keep pet out of patient’s bedroom, and
place free-standing HEPA air cleaner in patient’s bedroom
3. Nasal steroid sprays
-most effective allergy medicine available
-multiple trials show superior efficacy to oral antihistamines, Astelin, Singulair, etc.
-especially for the symptom of congestion
-most effective if used on a daily basis
-due to delayed onset of action
-but effective even with prn use
-current studies suggest excellent long-term safety profile
-clinical trials suggest equal efficacy between all nasal steroid sprays
-compliance is the key
-patients prefer unscented sprays
-Nasonex, Nasacort, Rhinocort, Omnaris and Veramyst (lowest volume of spray)
-patients prefer low co-pay
-Flonase is generic (but is scented)
-age indications
-Nasonex , Nasacort-AQ and Veramyst: 2 years and up
-Flonase: 4 years and up
-Rhinocort Aqua and Omnaris: 6 years and up
-technique of administering may decrease incidence of epistaxis
-avoid spraying towards the septum
4. First generation oral antihistamines
-studies show patients may have psychomotor impairment
-even without subjective sedation
-anticholinergic side effects are possible
-dry mouth, blurring of vision, urinary retention, etc.
5. Second generation oral antihistamines
-no anticholinergic side effects
-so no dry mouth nor urinary retention side effects
-so no benefit for rhinorrhea of colds or vasomotor rhinitis
-no significant decongestant properties
-so more beneficial for “runners” than “blockers”
-Cetirizine (Zyrtec)
-studies suggest superior efficacy
-low-sedating (not non-sedating)
-requires warning regarding driving and use with alcohol
-generic OTC is relatively inexpensive
-Levocetirizine (Xyzal)
-clinical trials showing superior efficacy to Zyrtec are lacking
-low-sedating (not non-sedating)
-requires warning regarding driving and use with alcohol
-Loratadine (Claritin)
-may not be as effective as other antihistamines
-generic OTC is relatively inexpensive
-Desloratadine (Clarinex)
-clinical trials showing superior efficacy to Claritin are lacking
-Fexofenadine (Allegra)
- combines effectiveness and safety
- The Medical Letter: April 30, 2001 and March 18, 2002
-available as a generic
6. Nasal antihistamine spray (Astelin and Astepro)
-indicated both for allergic and non-allergic rhinitis
-poor masking of the placebo may explain Astelin’s “efficacy” for non-allergic rhinitis
-bitter taste
-low sedating (not non-sedating)
-requires warning regarding driving and use with alcohol
7. Leukotriene receptor antagonist (Singulair)
-theoretically, should relieve congestion better than antihistamines
-however, not substantiated by clinical trials
-theoretically, combining antihistamine with leukotriene antagonist should be additive
-however, not substantiated by most clinical trials
-also indicated for asthma
-so may be a good option for patient with asthma and allergic rhinitis
8. Cromolyn sodium spray (Nasalcrom)
-OTC
-excellent safety profile, even in pregnancy
-frequent dosing required (t.i.d.-q.i.d.)
9. Immunotherapy
-subcutaneous injection of the antigens to which the patient is allergic
-begin at a low dose and gradually increase up to a long-term maintenance dose
-alters patient’s immune system
-so that their immune system no longer over-reacts to harmless environmental substances
-advantages
-addressing the underlying etiology (i.e. the immune system)
-outcome studies show better symptom control as compared to medications alone
-disadvantages
-potential for anaphylaxis
-20% of patients do not respond
-if respond, usually have to continue shots for 3 years or more
09/2010
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