Sinusitis and Unicorns

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Nathan Cleveland, MD, MS

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  • Well any time you see a title like this at ACEP there are really only two options: First, the speaker is trying to illicit some sort of emotional response from you or somehow make their topic more interesting to you than it would normally be, which I am. Or the speaker made the huge mistake of promising his two young daughters that he would talk about whatever they wanted at a national scientific assembly of his peers. My name is Nathan Cleveland, I’m from University medical Center in Las Vegas and the Univ of Nevada School of Medicine Residency in EM. Today I am, believe it or not, going to talk about sinusitis and unicorns.
  • Evidence-Based Medicine is what the gap between man and God. OK, maybe that is a bit of an exaggeration, but I fully admit that I am a disciple of EBM. I believe that almost every aspect of our practice should reflect the current best evidence when it exists.
  • The best definition for EBM is also probably one of the oldest definitions of EBM.
  • In its most basic form, EBM attempts to evaluate numerous diagnostic strategies in order to help us identify disease, then it evaluates numerous treatment strategies in order to help us know how to treat that disease and improve outcomes. But do we really need EBM for simple and common conditions like sinusitis? After all, we’re emergency medicine doctors, right? We’re in the business of STEMIs and sepsis. We can all manage a simple sinus infection with our hands tied behind our backs. I believe we do. And I believe that odds are, most people in this room don’t know the current best evidence for diagnosing and treating this condition.
  • The goals of this talk are to: 1. Review the current dogma that exists with regards to sinusitis and review current practice patterns. 2. Present the current best evidence available on sinusitis and 3. Focus on the current recommendations for managing sinusitis.
  • But before we get into that, let’s review the classification of sinusitis. It should actually be referred to as rhinosinusitis not sinusitis, since it is impossible to have sinusitis without rhinitis. And there are numerous forms of rhinosinusitis. But today we will be focusing on acute rhinosinusitis of which there are two types: acute bacterial rhinosinusitis and acute viral rhinosinusitis.
  • Historically we’ve been taught that you can differentiate viral from bacterial forms of the disease by historical features and physical exam. AVRS lasts less than 10 days, is self limited, usually bilateral and associated with non-purulent discharge while ABRS lasts longer, requires antibiotic treatment, is often unilateral, with purulent discharge and facial pain. I’m going to throw out all of that dogma. But before we get to that, it should be noted that the best epidemiological studies of these diseases estimate that viral etiology accounts for 98% of cases while bacterial represents less than 2%.
  • So what about the historical features? Well, it turns out that duration of symptoms and severity of symptoms are actually not at all predictive of viral versus bacterial etiology.
  • And physical exam? Terrible. Both viral and bacterial rhinosinusitis can produce unilateral or bilateral pain and sinus tenderness.
  • How about purulent nasal discharge? Well let me ask you this: how many of you here have children? I you do, you are a snot expert. Do any of you trust yourself to identify purulence? I’ve seen some crazy colored boogers but I have no idea whether that means it was purulent. And the literature confirms this…
  • And radiology gets an “epic fail” when it comes to diagnosing sinus infections. In fact, it is so bad that in one study published in 1994 in NEJM, 87% of patients who self report having a “common cold” and not sinus infection, actually have CT evidence of sinus mucosal thickening or fluid in the sinuses. So radiology actually means nothing when it comes to rhinosinusitis. Let me put it another way, how many of your trauma patients who receive a head CT are found to have sinusitis?
  • So maybe it’s not completely ridiculous to try to make this bizarre link between sinusitis and unicorns. They are both extremely rare, if not imaginary, and impossible to definitively identify.
  • Obviously I’m exaggerating a bit to try to make a point. Acute bacterial rhinosinusitis does exist, although very rarely. There are a few historical features and physical exam findings that should make you stop, and expand your work-up. These include any ocular or orbital involvement, severe headache, facial swelling (here is the classic pott’s puffy tumor) or altered mental status. All of these findings can suggest suppurative complications with extension of infection to adjacent structures. It should be noted, however, that in a review of placebo-controlled trials of antibiotics in sinusitis, no cases of orbital involvement or intracranial involvement were noted in the placebo groups – so they’re pretty rare.
  • The current problem is that, although most of us outgrow our belief in unicorns, the belief in the mythical sinus infection persists. Both primary care and emergency physicians seem to see sinus infection lurking around every corner. And current evidence is that 80% of patients who present with a complaint of “sinus infection” will walk out of the office or hospital with a prescription for antibiotics. That is an astounding number given the fact that we’ve already seen that 98% of cases of sinusitis are viral.
  • A cochrane review from the mid-1990s found that antibiotics were of little value for clinical resolution of symptoms. 47% of pts on antibiotics reported resolution of symptoms at 10-14d with an overall cure rate of 81%. As opposed to the placebo groups in which 32% reported resolution at 10-14d and 66% achieved overall cure. This yields a number needed to treat of 7. OK, so maybe there is some use for antibiotics right?
  • Subsequent studies from the same year however, have not yielded the same results. The first study here is a randomized controlled trial of amoxicillin in which there was no difference in cure rates, complications or relapse. Of note, 28% of the patients treated with antibiotics reported an adverse effect such as vomiting or diarrhea. The second study used doxycycline and again found no difference in clinical symptomatology in patient treated with antibiotics.
  • And finally, the most recent, and in my opinion, most definitive meta-analysis to date was performed in 2008 and published in Lancet. Although this Forest plot is probably to small to read, you see that overall, the benefit of antibiotics in treatment of acute rhinosinusitis is extremely small. And that benefit must be weighed against this: the Forest plot of adverse events in those same studies where those patients on antibiotics had a trend towards increased adverse events. The authors conclusions therefore are…
  • So in summary thus far, we have…
  • And yet 80% of the time we are prescribing antibiotics.
  • In 2001, a joint task force from the CDC, IDSA, AAFP and ACP published evidence-based recommendations for the management of acute rhinosinusitis.
  • Their recommendations could be summarized like this:
  • We recommend symptomatic treatment and reassurance as first line with a focus on pain medications and decongestants. And reserve antibiotics for only the most severe symptoms with coverage for strep pneumo and h flu. They go on to state that antibiotics should essentially never be prescribed in cases lasting less than 7 days – which in my experience encompasses the majority of patients we see in the emergency department.
  • I let my daughters believe in unicorns because it is harmless. Belief in the common sinus infection, however, is not harmless. Although it is beyond the scope of this talk to cover the risks of emerging antibiotic resistance, I think we’d all agree that when MRSA makes an appearance on Oprah, it’s time to be worried. In the future we all need to view acute bacterial rhinosinusitis as a rarity – almost as uncommon as the unicorn. And reserve antibiotics only for the most severe cases.
  • Sinusitis and Unicorns

    1. 1. E.B.M. FOR MYTHICAL BEASTS NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER LAS VEGAS, NV
    2. 2. E.B.M. FOR MYTHICAL BEASTS TITLE DOGMA INTRO CLASSIFICATION GOALS E.B.M. DIAGNOSIS UNICORNS E.B.M.
    3. 3. E.B.M. FOR MYTHICAL BEASTS WARNING E.B.M. “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.” -David Sackett, MD Sackett DL, et al. BMJ 1996; 312(7023):71-2 TITLE DOGMA INTRO CLASSIFICATION GOALS E.B.M. DIAGNOSIS UNICORNS
    4. 4. E.B.M. FOR MYTHICAL BEASTS E.B.M. DISEASE WARNING TITLE DOGMA INTRO CLASSIFICATION GOALS E.B.M. DIAGNOSIS UNICORNS
    5. 5. E.B.M. FOR MYTHICAL BEASTS THE PROBLEM GOALS WARNING DOGMA INTRO CLASSIFICATION GOALS E.B.M. DIAGNOSIS UNICORNS 1. Review the dogma 2. Current best evidence 3. Recommendations
    6. 6. E.B.M. FOR MYTHICAL BEASTS EVIDENCE SINUSITIS RHINOSINUSITIS ACUTE ABRS AVRS RECURRENT INFECT. ALLERG. CHRONIC POLYPS NO POLYPS FUNGAL THE PROBLEM WARNING DOGMA CLASSIFICATION GOALS E.B.M. DIAGNOSIS UNICORNS
    7. 7. E.B.M. FOR MYTHICAL BEASTS SUMMARY THE DOGMA AVRS 7-10 days Self-limited Bilateral Non-purulent 98%-99.5% ABRS >10 days Needs Tx Unilateral Purulent Facial pain 0.5%-2% Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007;45(2):97. EVIDENCE THE PROBLEM WARNING DOGMA CLASSIFICATION GOALS DIAGNOSIS UNICORNS
    8. 8. E.B.M. FOR MYTHICAL BEASTS RECS RHINOSINUSITIS Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72 • Historical features SUMMARY EVIDENCE THE PROBLEM WARNING DOGMA CLASSIFICATION DIAGNOSIS UNICORNS
    9. 9. E.B.M. FOR MYTHICAL BEASTS RHINOSINUSITIS • Historical features • Physical exam Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72 RECS SUMMARY EVIDENCE THE PROBLEM WARNING DOGMA CLASSIFICATION DIAGNOSIS UNICORNS
    10. 10. E.B.M. FOR MYTHICAL BEASTS RHINOSINUSITIS Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician. 2004 Nov 1;70(9):1685-92. • Historical features • Physical exam • Purulence RECS SUMMARY EVIDENCE THE PROBLEM WARNING DOGMA CLASSIFICATION DIAGNOSIS UNICORNS
    11. 11. E.B.M. FOR MYTHICAL BEASTS RHINOSINUSITIS Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med. 1994;330(1):25 • Historical features • Physical exam • Purulence • Radiology RECS SUMMARY EVIDENCE THE PROBLEM WARNING DOGMA CLASSIFICATION DIAGNOSIS UNICORNS
    12. 12. E.B.M. FOR MYTHICAL BEASTS UNICORNS A.B.R.S. RECS SUMMARY EVIDENCE THE PROBLEM WARNING DOGMA DIAGNOSIS UNICORNS
    13. 13. E.B.M. FOR MYTHICAL BEASTS THE END A.B.R.S. OCCULAR/ ORBITAL SEVERE HEADACHE FACIAL SWELLING ALTERED MENTATION Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and Prevention. Annals of Emergency Medicine. 2001;37(6):703-10 • No cases due to placebo UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM WARNING DIAGNOSIS UNICORNS
    14. 14. E.B.M. FOR MYTHICAL BEASTS THE PROBLEM 80% Receive antibiotics!! Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and Prevention. Annals of Emergency Medicine. 2001;37(6):703-10 THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM WARNING UNICORNS
    15. 15. E.B.M. FOR MYTHICAL BEASTS EVIDENCE Systematic Review Williams JW Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a systematic literature review. In: Douglas R, et al., eds. Acute Respiratory Infections Module of The Cochrane Database of Systematic Reviews. The Cochrane Library. 1997. ABX 47% at 10-14d 81% Cure No ABX 32% at 10-14d 66% Cure NNT = 7 THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM WARNING
    16. 16. E.B.M. FOR MYTHICAL BEASTS EVIDENCE Stalman W, van Essen GA, et al. Br J Gen Pract. 1997;47:794-9 Lancet. 1997;349:683-7 THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM WARNING
    17. 17. E.B.M. FOR MYTHICAL BEASTS EVIDENCE Lancet Infect Dis. 2008;8(9):543 THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM WARNING
    18. 18. E.B.M. FOR MYTHICAL BEASTS SUMMARY Disease rare Diagnosis difficult Mostly harmless Treatment modest THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM
    19. 19. E.B.M. FOR MYTHICAL BEASTS SUMMARY THE END UNICORNS RECS SUMMARY EVIDENCE THE PROBLEM 80%
    20. 20. E.B.M. FOR MYTHICAL BEASTS Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Int Med. 2001;134(6):495-97 THE END UNICORNS RECS SUMMARY EVIDENCE
    21. 21. E.B.M. FOR MYTHICAL BEASTS TREATMENT SINCE: • Most ARS is viral • Bacterial/viral cannot be differentiated • Most ABRS improves without Tx THE END UNICORNS RECS SUMMARY EVIDENCE
    22. 22. E.B.M. FOR MYTHICAL BEASTS TREATMENT RECOMMENDED: • Symptomatic Tx and reassurance • Pain medication • Decongestants • Abx only for severe symptoms • Cover for s. pneumoniae and h. influenza THE END UNICORNS RECS SUMMARY EVIDENCE
    23. 23. E.B.M. FOR MYTHICAL BEASTS THE END UNICORNS RECS SUMMARY
    24. 24. E.B.M. FOR MYTHICAL BEASTS THE END UNICORNS RECS QUESTIONS?
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