Acute Rhinosinusitis
For Pharmacy Examining Board of Canada (PEBC) MCQ and EE Preparation
Introduction
Acute rhinosinusitis refers to the symptomatic inflammation of the nasal cavity and one or more of the paranasal sinuses. This chapter will focus on episodes lasting ≤4 weeks. Chronic rhinosinusitis persists for ≥12 weeks, while subacute rhinosinusitis lasts between 4 to 12 weeks. Acute rhinosinusitis is most often viral in origin, but it may sometimes be complicated by bacterial infection. Understanding the clinical presentation, therapeutic interventions, and management options for both viral and bacterial rhinosinusitis is crucial for the PEBC exam.
Goals of Therapy
The therapeutic goals in managing acute rhinosinusitis are:
- Reducing symptoms (nasal congestion, purulent discharge, facial pain).
- Eradicating the infection in cases of bacterial involvement.
- Preventing recurrence of infection.
- Minimizing unnecessary antibiotic use to reduce antibiotic resistance.
Investigations
History and Physical Examination
● Viral Rhinosinusitis: Typically follows a viral upper respiratory tract infection (URTI), with rhinovirus, adenovirus, influenza virus, and parainfluenza virus being common causes.
● Bacterial Rhinosinusitis: Suspected when symptoms last >10 days without improvement or worsen after an initial improvement ("double sickening").
Diagnostic Criteria
● PODS Mnemonic: Helps remember the four cardinal symptoms of rhinosinusitis:
○ P: Facial Pain
○ O: Nasal Obstruction
○ D: Purulent nasal Discharge
○ S: Smell disorder (anosmia or hyposmia)
Physical exam findings may include purulent nasal discharge, nasal cavity inflammation, and tenderness over the sinus areas.
Complicated Disease
Red flags that indicate complicated acute rhinosinusitis include altered mental status, orbital or intracranial complications (e.g., periorbital edema, visual disturbances, severe headache), and systemic symptoms. Refer to an ENT specialist if complications are suspected.
Therapeutic Choices
Non-Pharmacologic Options
● Saline Nasal Irrigation: Helps thin mucus, clear inflammatory mediators, and improve mucociliary function.
● Warm Compresses and Rest: May provide symptomatic relief.
Pharmacologic Management
Symptom Management
● Analgesics: Acetaminophen or ibuprofen can be used for pain and fever control.
● Intranasal Corticosteroids (INCS): May provide symptomatic relief by reducing inflammation. Consider a 72-hour trial of high-dose INCS in mild-to-moderate rhinosinusitis before initiating antibiotics.
Antibiotic Therapy
Antibiotics are generally reserved for bacterial rhinosinusitis, especially in patients with:
- Symptoms lasting >10 days without improvement.
- Symptoms that worsen after initial improvement.
The common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Algorithm for Management of Acute Rhinosinusitis
|
Step |
Action |
|
1. Patient presents with signs and symptoms of acute rhinosinusitis |
Assess for the presence of PODS (Pain, Obstruction, Discharge, Smell Disorder). |
|
2. Are red flags present? |
Yes: Refer to emergency. No: Continue below. |
|
3. Symptom duration ≤10 days |
Recommend watchful waiting (most cases are viral). Provide education, saline irrigation, acetaminophen, or ibuprofen for pain/fever. Consider 72-hour trial of INCS. |
|
4. Symptom duration >10 days or worsening after improvement |
Consider bacterial rhinosinusitis. Initiate antibiotic therapy or continue watchful waiting with INCS. |
|
5. Reassess after 7 days of antibiotic therapy or INCS trial |
If no improvement, refer for further evaluation. |
Antibiotic Choices for Bacterial Rhinosinusitis
|
Drug |
Dose |
Common Adverse Effects |
|
Amoxicillin |
Adults: 500 mg–1 g TID PO |
Nausea, vomiting, diarrhea, rash |
|
Amoxicillin/Clavulanate |
Adults: 875 mg BID PO |
Nausea, diarrhea, hypersensitivity |
|
Cefuroxime (Ceftin) |
Adults: 500 mg BID PO |
Nausea, vomiting, diarrhea, rash |
|
Doxycycline |
Adults: 100 mg BID PO |
Nausea, photosensitivity, rash |
|
Levofloxacin (fluoroquinolone) |
Adults: 750 mg daily PO |
Tendonitis, QT prolongation, dizziness |
Therapeutic Notes for Exam Preparation
● First-Line Antibiotic for Bacterial Rhinosinusitis: Amoxicillin or Amoxicillin/Clavulanate.
● Watchful Waiting: Patients can safely wait up to 7 days after diagnosis of bacterial rhinosinusitis before starting antibiotics if symptoms are not severe.
● Duration of Antibiotic Therapy:
○ Adults: 5–7 days of therapy is usually sufficient.
○ Children: 10 days of therapy is recommended.
● High-Dose Amoxicillin: Recommended for children at high risk of antibiotic-resistant S. pneumoniae (e.g., daycare attendees or recent antibiotic use).
Important Points for PEBC Exams
- Antibiotics are not routinely needed in acute rhinosinusitis as most cases are viral.
- Watchful waiting is a safe approach for mild-to-moderate cases of bacterial rhinosinusitis.
- INCS can be used as an antibiotic-sparing strategy in mild-to-moderate rhinosinusitis.
- Risk factors for antibiotic resistance include recent antibiotic use (<3 months) and daycare attendance in children.
- Red Flag Symptoms: Altered mental status, visual disturbances, and orbital complications warrant immediate referral.
- Duration of Therapy: Shorter antibiotic courses (5–7 days) are preferred in uncomplicated cases to reduce side effects and resistance.
Conclusion
Acute rhinosinusitis is typically viral and self-limiting, with symptom management being the primary focus. Antibiotic therapy is reserved for patients with bacterial involvement, characterized by symptoms persisting beyond 10 days or worsening after an initial improvement. For PEBC exams, candidates should focus on the differential diagnosis of bacterial versus viral rhinosinusitis, appropriate use of antibiotics, and the management of complications.