Rhinosinusitis(RS), Acute

Clinic A/P, adults

Most cases of RS are caused by viral URIs. Cannot distinguish b/n viral and bacterial causes based on s/sx alone.
Diagnosis
-H&P consistent with acute RS.
-OPQRST-A
-Duration of URI s/sx? =______
–Double sickening present?
-Purulent nasal secretion?
-Is purulent rhinorrhea predominantly unilateral?
Labs: ESR
Treatment
–Watchful waiting with symptomatic tx for the first 7 to 10 days of the URI s/sx.
-Consider abx Rx when RS symptoms fail to improve within 7 to 10 days or if they worsen at any time.
–1st-line abx =  Amoxicillin ± clavulanate. i.e. Amoxicillin or Augmentin.
-CT w/o contrast of the sinuses if pt doesn’t respond to tx to eval for complications or anatomic abnormalities.
-Refer to otolaryngology if s/sx persist after maximal Rx and if any rare complications are suspected.

—/END/—

  • Unilateral predominance with purulent rhinorrhea is suggestive of bacterial sinusitis. “One study showed that unilateral predominance with purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis. After 10 days of upper respiratory symptoms, the probability of acute bacterial rhinosinusitis is 60%.”
  • Double sickening, purulent rhinorrhea, purulent secretion in the nasal cavity, and an ESR > 10 mm/hr b/c these four S/Sxs significantly increase the likelihood of a bacterial cause when present.
  • ENT (otolaryngologist)
  • CRP and ESR are somewhat useful for confirming acute bacterial maxillary sinusitis.
  • May use analgesics, intranasal corticosteroids, and saline nasal irrigation to treat symptoms within the first 10 days of the URI.
  • “Do not routinely prescribe antibiotics for acute, mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions and maxillary pain or facial and dental tenderness to percussion) last at least seven days or symptoms worsen after initial clinical improvement.” American Academy of Allergy, Asthma and Immunology
  • “Mild rhinosinusitis symptoms lasting fewer than 10 days can be managed with supportive care, including analgesics, intranasal corticosteroids, and saline nasal irrigation.” AAFP
  • “In uncomplicated acute bacterial rhinosinusitis, watchful waiting (without antibiotics) is an appropriate initial management strategy when there is assurance of follow-up.” AAFP

Resources:
http://www.aafp.org/afp/2016/0715/p97.html

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