Outpatient / Infectious Disease
Rhinosinusitis
# *** (Acute/Chronic) Rhinosinusitis
Intake
-- Onset: *** (acute <1mo, chronic >3m)
-- Symptoms: *** (fevers, rhinorrhea, unilateral purulence, facial pressure/pain, cough, HA, anosmia, ear fullness)
-- Initial Improvement?: ***
-- Risk Factors For Resistance: *** (age 65+, comorbidity, high fevers, immunosuppressed, or recent hospitalization or abx use)
-- Number of Annual Episodes: *** (4 or more is considered recurrent)
-- Red Flags: *** (fevers >102; severe HA, AMS, eye pain, swelling, impaired vision, double vision, skin discoloration suggesting necrosis)
Plan
-- Abx: *** if indicated (>10 days without impovement, fever to 102 for 3 days, worsening symptoms after initial improvement) give augmentin 875/125mg q12 for 5-7 days or 2g q12 if RF for resistance; doxy 875mg BID if PCN allergy
-- Fever/Pain: *** Tylenol 325-1000mg q6 for pain;
-- Congestion: saline irrigation, fluticasone nasal spray PRN, pseudoephedrine 30mg q6 PRN; oxymetolazone spray 2-3 sprays per nostril twice daily for max 3 days (avoid in HTN)
-- Avoid steroids and anithistamines
-- Smoking cessation
-- CT of the sinuses if recurrent disease, concern for red flags, or concern for fungal involvement
Template PDF coming soon!
Patient Guidance and Information
Acute Sinusitis
It sounds like you are having an episode of acute sinusitis. Based on your history and symptoms, we are *** concerned there may be a bacterial infection.
We recommend treating with *** augmentin twice daily for *** 7 days.
You can also take tylenol or ibuprofen for pain, saline irrigation, fluticasone nasal spray, and pseudoephedrine for congestion.
We can plan to re-assess your symptoms in 3 days.
If You Remember Nothing Else
Few sinusitis infections are caused by bacteria and benefit from antibiotics. Treat with augmentin if the symptoms have been present for greater than 10 days without impovement, they have had a fever to 102 for 3 days, or there are worsening symptoms after initial improvement. Otherwise, treat supportively.
Clinical Pearls
- When to Refer: chronic sinusitis (>12 weeks), recurrent sinusitis, concern for fungal involvement
- A nasal endoscopy to visualize tissue can be especially helpful if c/f granulomatous or fungal dx
- Bacterial is only 0.5-2% of acute rhinosinusitis - most commonly strep pneumo and H flu
- Treating sinusitis with abx only reduced symptoms for a half day; not treating does NOT put at risk for chronic sinusitis
- In patients with chronic rhinosinusisits - it's an inflammatory disease (associated with asthma, granulomatous disease, CF, immunodeficiency, etc)
- Should consider migraine as part of differential for patients with chronic sinusitis and trial empiric meds
- Guaifenesin is an expectoarant that decreases adhesiveness and surface tension of sputum allowing for improved clearance - it is most helpful in wet cough
- Can’t miss complications include spread to the orbit, cranium, or fungal involvement
- Risks for mucor are DM and immunosuppression - surgical emergency to debride
Trials and Literature
- NEJM Review Acute Sinusitis in Adults
- Meta-Analysis suggests better cure rate between 7 and 14 days with abx (73% vs 64%) NNT 11 with GI side effects with NNH 8; one example of RCT showing abx don’t help, but nasal steroids might
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