Journal Article:

sinus_nejmcp1601749

Summary:

Daniel DeMarco                        Journal Article Assignment                        Ambulatory Care

Acute Sinusitis in Adults

The New England Journal of Medicine

Rosenfeld, RM

Definition:

· Sinusitis:

· Symptomatic inflammation of paranasal sinuses and nasal cavity

· AKA rhinosinusitis 2/2 involvement of both paranasal sinuses and nasal mucosa

Epidemiology:

· 30 million adults annually in US

Etiology:

· MCC: Viral upper respiratory tract infections (pathogens)

· Most common bacterial pathogens: S pneumoniae, H influenzae, M catarrhalis, S aureus

· Increased association in patients with asthma, allergic rhinitis, smoking, second-hand smoke exposure

Classification:

· Duration:

· Acute: Up to 4w

· Subacute: 4w-3m

· Chronic: >3m

· Presumed Cause:

· Acute Viral Sinusitis versus Acute Bacterial Sinusitis: Up to 90% with viral URTI have concurrent acute viral sinusitis; only 0.5 to 2.0% have sinusitis that progresses to bacterial sinusitis

– Viral Upper Respiratory Sx: peak rapidly, decline by day 3, ends after 1w

– Acute Bacterial Sinusitis: > or = to 10d or longer without improvement or worsening of sx after initial improvement

Disease Progression:

· Approx. 85% of patients have reduction/resolution of sx w/in 7-15d w/o antibiotic therapy. Though abx are rx in 84-91% of cases likely 2/2 to patient expectations and inconsistency between clinical guidelines and abx rx patterns

Clinical S/Sx:

· Purulent anterior/posterior nasal drainage (most accurate diagnostic criterion) +/- nasal obstruction

· Facial pain/pressure/fullness

· If periorbital edema, pain/restriction of EOMs, severe h/a think about complications

Diagnostic Imaging:

· XR/CT is not useful in distinguishing b/w bacterial and viral infection

· Reserved for patients with suspected complications (eg orbital/intracranial involvement)

Management Considerations:

· Most literature shows no effect on median duration of pain or illness in patients treated with abx versus placebo (no abx)

· Some literature shows small, but statistically significant, higher rates of clinical improvement in abx therapy. One systematic review reported success rates of 77-88% with abx therapy versus 73-85% in no abx

· Another systematic review with stricter inclusion criteria (illness > or = to 7d) reported no significant benefit in abx therapy over placebo (rate of improvement after 10d 88% versus 85%, respectively)

· Systematic review reports similar incidence of complications like cellulitis, meningitis, and orbital or intracranial abscess b/w abx and no abx

· No difference in comparative efficacy of abx reported in the literature; likely b/c high rate of spontaneous improvement (w/ or w/o abx)

· Systematic review reported no statistically significant difference in clinical success in abx regimens for 3-7d versus 6-10d; odds of ADRs were 21% lower in those with shorter course of treatment

· NNT for 1 patient to experience clinical improvement with abx ranges from 7-18.

· NNH (# patients who receive abx for one ADR to occur) ranges from 8-12

· The NNT and NNH indicate that ADRs from abx are as likely, or more likely than, benefits

· Consideration of ADRs to abx: allergic reactions, drug-resistant bacteria

· Adjuvant Therapies: topical intranasal corticosteroids conferred small but significant decrease in symptoms (pain, nasal congestion); oral glucocorticoids with slightly higher rates of improvement (though methodologic limitations and fact that systemic CS have associated risks, this is not recommended); conflicting reports on efficacy of nasal irrigation; literature on efficacy of decongestants, antihistamines and guaifenesin are lacking

· Special Populations:

· Pregnant Women: medical mimic – differentiate from nasal vascular engorgement (rhinitis of pregnancy)

· DM or Immunocompromised: more likely to harbor resistant bacteria; if high temperature, nasal crusting, severe facial pain must consider invasive fungal sinusitis (medical emergency)

· Refractory illness/Recurrent Bacterial Sinusitis (3+ in 6m)/Suspicion of developing orbital/intracranial complication: referral to ENT

Abx Recommendations:

· Guidelines differ! American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) state watchful waiting is similar to abx therapy. Infectious Diseases Society of America (IDSA) recommend all patients receive abx as initial treatment.

· Definitions of treatment failure differ! AAO-HNS states failure occurs if no reduction in sx by 7d. Other guidelines state failure occurs if no reduction in sx by 2-5d.

· If pregnant and abx indicated: amoxicillin, amoxicillin-clavulanate; if PCN-allergic then clindamycin + cefixime or cefpodoxime

· If DM and/or immunocompromised then amoxicillin-clavulanate, if no sx improvement w/in 72h then nasal culture with c/s.

· If treatment failure: Augmentin 2000-125 bid x10d, Doxycycline 200mg x10d

· Do not use clarithromycin or azithromycin 2/2 macrolide-resistant S pneumoniae

· Reserve fluoroquinolones for those with no alternative treatment options

Authors’ Recommendations:

· Initial management based on shared decision making

· If watchful waiting, consider delayed antibiotics: use if illness worsens, sx do not decrease w/in 7d

· If abx are initial therapy: Amoxicillin 1000mg tid x 5d

· If comorbidities (DM, immunosuppression): Augmentin 500-125 tid x 5-10d or 875-125 bid x 5-10d

· If PCN-allergic: Doxycycline 200mg (daily) x 5d

· For sx (facial pain, pressure, fullness): analgesics, nasal glucocorticoids, nasal decongestant (oxymetazoline) x 5d only (risk of rebound congestion); consider nasal rinse; antihistamines only if known allergies; No oral corticosteroids