rhinosinusitis%20-%20acute,%20bacterial
RHINOSINUSITIS - ACUTE, BACTERIAL
Acute bacterial rhinosinusitis is the mucosal inflammation of the nose and paransal sinuses caused by bacteria lasting >10 days for up to 4 weeks or symptoms worsening for 5-7 days and is <12 weeks with complete resolution of symptoms.
It is often preceded by a viral upper respiratory tract infection.
Signs and symptoms are nonspecific and typically difficult to differentiate from viral upper respiratory tract infection.
There is fever with nasal obstruction/congestion or anterior and/or posterior purulent drainage, with or without facial pressure/pain/fullness and reduction/loss of smell.
Streptococcus pneumoniae and unencapsulated strains of Haemophilus influenzae cause half of acute rhinosinusitis cases.

Diagnosis

  • Targeted history and physical exam are both beneficial and cost-effective during initial diagnosis
  • Acute viral, non-infectious and allergic rhinosinusitis must be ruled out to prevent inappropriate antibiotic treatment
  • Most guidelines diagnose acute bacterial rhinosinusitis (ABRS) based on clinical presentation
    • Gold standard for ABRS diagnosis is ≥104 colony-forming units (CFU)/mL of bacteria from paranasal sinus cavity
  • Diagnosis should be based on at least 3 of the following signs and symptoms:
    • Fever (>38°C)
    • Presence of severe local pain
    • With discolored discharge and purulent nasal secretion (nasal cavity)
    • Increased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
    • Patients become worse at initial recovery or deterioration of signs and symptoms 
  • A presumptive diagnosis of ABRS should be made if patient presents with any of the following:
    • Persistent illness - presence of >10 days nasal discharge or daytime cough not relieved by medications
    • Worsening course - worsening of resolved previous or new onset nasal discharge, daytime cough, headache or pyrexia
    • Severe onset of the disease - fever ≥39°C with purulent nasal discharge or facial pain of ≥3 days duration

Evaluation

Severity of Acute Bacterial Rhinosinusitis (ABRS)

  • The severity of ABRS will reflect the need for antibiotic therapy
    • Mild ABRS may be managed with symptomatic therapy alone
    • Severe ABRS will need outright antibiotic management plus symptomatic medications
  • The severity assessment will also guide the analgesic therapy
  • Differences in severity do not necessarily imply antimicrobial resistance
  • The evaluation of disease severity will be dependent on clinical judgment
  • Evaluation of disease severity may be based on total severity visual analogue scale (VAS) score
    • Mild: VAS 0-3 cm
    • Moderate: VAS >3-7 cm
    • Severe: VAS >7-10 cm
  • Patients with moderate disease are more likely to need therapeutic intervention to achieve symptom resolution
    • Treatment failures will more likely be less tolerable in these patients
  • Severe or life-threatening illnesses should be referred to an emergency dept (ED) or otolaryngologist

Recent Antibiotic Use

  • Recent antibiotic use (within the last 4-6 weeks) is a major factor that is associated with increased risk of resistant pathogens

History

  • Persistent symptoms are moderately sensitive but are nonspecific predictors of acute bacterial rhinosinusitis (ABRS)
  • Pay particular attention on the speech which may indicate fullness of the sinuses
  • It is also important to include questions on allergic symptoms

Physical Examination

  • Examine the face for periorbital edema or other facial swelling
  • Perform anterior rhinoscopy when examining the nose 
    • Used for clinical assessment of patients suspected with acute rhinosinusitis (ARS) (primary care setting) 
    • May reveal polyps, inflammation, mucosal edema, purulent discharges, tumors, foreign bodies and other anatomical abnormalities (eg deviated septum)
  • Examination of the ears may reveal concomitant otitis media
  • Percussion or direct pressure over the body of the frontal and maxillary sinuses may produce unilateral pain
  • Tapping of the maxillary teeth with a tongue depressor can be used to test for tenderness
  • Transillumination is of limited usefulness

Imaging

Nasal Endoscopy
  • Rigid endoscopy is preferred because it provides clear images and is more comfortable for patients 
  • Facilitates culture and tissue sampling
  • Enables endoscopists to perform nasal toileting

Computed Tomography (CT) Scan

  • Gold standard in the evaluation of the paranasal sinuses
  • Used in quantifying the extent of inflammatory disease
    • This is based on the opacification of the paranasal sinuses
  • Indications for CT scan:
    • Presence of unilateral symptoms, blood-stained discharge, displacement of the eye and eye pain
    • Planning for a surgery
    • Failure of medical therapy
  • Contrast-enhanced CT scan rather than MRI is recommended for acute bacterial rhinosinusitis (ABRS) which is unresponsive to medical management, and those with suspected suppuration

 Magnetic Resonance Imaging (MRI)

  • MRI with contrast of the paranasal sinuses may be considered for pediatric and adult patients suspected of orbital or central nervous system (CNS) involvement

Chest Radiography

  • Not required to diagnose ARS unless complications or alternative diagnoses are entertained 

Laboratory Tests

Culture and Susceptibility Test

  • Documents bacterial infection and resistance pattern
  • Cultures from direct aspiration of sinus are recommended in patients who have failed empiric therapy
    • Alternative could be culture from middle meatus via endoscopy
    • Nasopharyngeal swab culture is not recommended

Other Procedures

Maxillary Sinus Taps (MST) for Sinus Puncture and Aspiration

  • The gold standard in determining the etiology of ABRS
    • Due to its invasive nature, this procedure is rarely performed

Endoscopically-Directed Middle Meatal Culture (EDMMC)

  • A less invasive procedure than MST
  • Has comparable performance with a sinus CT scan
  • May also be used in obtaining the specimen for culture and susceptibility tests for unresolved cases of bacterial rhinosinusitis

Differential Diagnosis

  • Acute invasive fungal rhinosinusitis
    • Has similar symptoms with ARS but in acute invasive fungal rhinosinusitis, the symptoms rapidly progress and the infection has already extended outside the sinuses at presentation
    • Patients with uncontrolled diabetes and those who are immunocompromised are the ones who usually develop acute invasive fungal rhinosinusitis
  • Common cold
    • The symptoms of common cold and ARS may overlap (eg sneezing, anterior or posterior rhinorrhea), but the common cold generally does not have facial pain
    • Associated with sore throat or cough
  • Other conditions that cause rhinitis, facial pain, headache or dental pain
    • Allergic rhinitis and nonallergic vasomotor rhinitis may present with rhinorrhea and nasal congestion, but can be distinguished from ARS in the presence of nasal congestion, rhinorrhea, sneezing and nasal itching
    • Facial pain or pressure, headache or purulent nasal drainage are absent in allergic rhinitis
    • Facial pain is present in patients with neuralgias, cancer pain, temporomandibular joint disorder or carotidynia and these patients do not present with the other symptoms of ARS
    • Patients with dental pain should be directly asked for prior dental procedures as they may have referred pain without an actual infection within the sinuses
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