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- 1. 253 © Springer Nature Switzerland AG 2021 A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology, https://doi.org/10.1007/978-3-030-54088-3_23 Acute Sinusitis and Its Complications Matthew Kim, Aaron Pearlman, Ashutosh Kacker, and Michael G. Stewart 23.1 Introduction Rhinosinusitis is one of the most commonly diagnosed and treated disease entities within oto- rhinolaryngology. Contemporary understanding of rhinosinusitis as more than simply an anatomic or infectious pathologic process has led to a more sophisticated nosology in the realm of rhinosi- nusitis, including distinctions based on chronic- ity and etiology, with even more specific classifications based on pathophysiologic mecha- nisms now coming to fruition. While this para- digm shift is best evidenced by current concepts surrounding the diagnosis and management of chronic rhinosinusitis, there has been a similar evolution in philosophy with regard to diagnosis of acute rhinosinusitis and the role and timing of antibiotic therapy. This chapter reviews the eval- uation and treatment of acute viral rhinosinusitis, acute bacterial rhinosinusitis, and recurrent acute rhinosinusitis. Orbital and intracranial compli- cates of acute bacterial rhinosinusitis and their management are also reviewed. M. Kim · A. Pearlman · A. Kacker · M. G. Stewart (*) Department of Otolaryngology—Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA e-mail: mk3183@cumc.columbia.edu; anp2022@med.cornell.edu; ask9001@med.cornell.edu; mgs2002@med.cornell.edu 23 Key Points • AVRS accounts for most cases of ARS. • AVRS and AR can predispose for devel- opment of ABRS. • Diagnosis of ARS (including AVRS and ABRS) is primarily clinical. • Initial management of ARS consists of supportive therapy. • Antibiotics should be considered after 7 days of symptoms or double-worsening. • Further evaluation, including imaging, should be considered in patients with treatment failure or suspected complications. • Management of orbital complications usually entails parenteral antibiotics and multidisciplinary evaluation, with sur- gery typically reserved for Chandler grades III-V. • Management of intracranial complica- tions entails parenteral antibiotics, sur- gery, and multidisciplinary evaluation. • Episodes of RARS are managed simi- larly to ABRS, with surgery reserved for patients with frequent infections. • Immunologic testing and imaging (to evaluate for anatomic factors and rule out CRS) may be helpful in RARS.
- 2. 254 23.1.1 Classification • Acute rhinosinusitis (ARS) refers to inflam- mation of the nasal cavity and paranasal sinuses lasting up to 4 weeks. The term “rhi- nosinusitis” is preferred over sinusitis because there is almost always a component of rhinitis with sinusitis – – 4–12 weeks: subacute rhinosinusitis – – 12 weeks: chronic rhinosinusitis (CRS) • Acute bacterial rhinosinusitis (ABRS) refers to secondary bacterial infection of the parana- sal sinuses • Acute invasive fungal sinusitis refers to a life- threatening, fulminant fungal infection seen in immunocompromised individuals (see chapter on fungal sinusitis) 23.1.2 Epidemiology • One of the most common health complaints prompting medical evaluation and antibiotic prescription – – Global prevalence 6–15% • Associated with significant healthcare expen- ditures and decreased productivity • Majority of cases occur in association with viral upper respiratory tract infection – – Allergic rhinitis is also common predispos- ing factor. • Other risk factors include: – – Age (15 or 45 years) – – Smoking history – – Anatomic variants (deviated nasal septum, concha bullosa, nasal polyposis) – – Nasal foreign bodies (including nasal can- nula, nasogastric tube) 23.1.3 Pathophysiology • Most frequently caused by viral infection – – Symptom onset within 24 h of infection – – Most common pathogens: rhinovirus influenza parainfluenza adenovirus • Progression to ABRS in 0.5–2% – – Mucosal edema → ↓mucociliary clear- ance → mucus stasis → bacterial superinfection – – Most common pathogens: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococ- cus aureus (Table 23.1) 23.1.4 Clinical Presentation • Acute viral rhinosinusitis (AVRS) and ABRS present with similar symptoms • Nasal symptoms – – Congestion/obstruction – – Purulent rhinorrhea/postnasal drip – – Facial pain/pressure – – Decreased olfaction • Extranasal symptoms – – Fever – – Fatigue – – Cough – – Ear pressure/fullness – – Throat pain – – Dental pain – – Halitosis – – Headache • Features suggestive of ABRS – – Lack of improvement after 7–10 days – – “Double sickening or worsening” (worsen- ing after a period of improvement) Table 23.1 Causes of ARS (descending frequency) Acute rhinosinusitis Viral Rhinovirus Influenza Parainfluenza Adenovirus Bacterial Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Fungal Aspergillus spp. Zygomycetes (Rhizopus, Rhizomucor, Mucor, Absidia) M. Kim et al.
- 3. 255 23.1.5 Diagnostic Evaluation • Exam findings – – Facial exam: edema/erythema, tenderness – – Anterior rhinoscopy: mucosal edema, tur- binate hypertrophy, copious clear or puru- lent rhinorrhea – – Oral exam: postnasal drainage, pharyngeal erythema • Nasal endoscopy helpful in certain cases – – Severe symptoms – – Unilateral disease – – Failure to respond to treatment – – Suspected mass – – Recent surgery – – Immunocompromised patient – – Suspected complicated infection • Diagnosis based primarily on history and exam – – Routine imaging NOT indicated – – Imaging indicated under special circumstances Suspected orbital or intracranial complication Suspected recurrent acute rhinosinusitis – – Comparison of imaging modalities Ultrasonography: not recommended Plain film radiography (X-ray): histori- cally used, not recommended Computed tomography (CT): excellent bony resolution, radiation exposure Magnetic resonance imaging (MRI): excellent soft tissue resolution, no radia- tion exposure, sensitive for intracranial and orbital infection • Cultures – – Not required for diagnosis, but can have treatment implications – – Middle meatal cultures correlate well with maxillary sinus aspiration – – Nasal or nasopharyngeal swab cultures not clinically useful 23.1.6 Treatment • Symptomatic relief – – Indicated for both AVRS and ABRS – – Systemic agents: analgesics/antipyretics, decongestants, mucolytics – – Topical agents (sprays): steroids, saline, decongestants (limit use to 3–5 days) • Antimicrobial therapy for ABRS – – Watchful waiting appropriate up to 7 days after diagnosis – – Antibiotics typically started for clinical worsening or persistent symptoms after 7 days – – First-line antibiotic choice is amoxicillin or amoxicillin/clavulanate Alternatives in Penicillin-allergic patients: third-generation cephalospo- rin ± clindamycin, doxycycline, fluoroquinolone • Macrolides and trimethoprim- sulfamethoxazole no longer recom- mended for initial therapy due to increasing prevalence of resistance – – Duration of treatment 5–10 days – – Risk of antibiotic therapy Allergic reactions GI upset Development of bacterial resistance • Treatment failure: worsening or failure to improve after 7 days of initial treatment – – Consider alternate diagnoses Facial pain and headache syndromes Rhinitis Nasal airway obstruction – – Evaluate for possible complications of ABRS (see below) – – Middle meatal cultures – – Change antibiotic High-dose amoxicillin/clavulanate Respiratory fluoroquinolone – – Failure of multiple antibiotic courses Imaging to evaluate for anatomic abnor- mality or complicated ABRS Middle meatal culture – – Relapse after treatment Mild → longer course of same antibiotic Moderate to severe → consider change in antibiotic and/or imaging • Oral steroids not recommended for routine use – – Not helpful as monotherapy 23 Acute Sinusitis and Its Complications
- 4. 256 – – May shorten time to symptom resolution when used in conjunction with antibiotics Risk of adverse effects • Oral antihistamines not recommended for ABRS – – May be helpful in allergic patients for AVRS – – Can lead to nasal dryness – – Can cause drowsiness and xerostomia (Fig. 23.1) 23.1.7 Complications • Suspect in patients with atypical signs and symptoms: – – Persistent high fever – – Periorbital edema/erythema, proptosis, diplopia/extraocular motility impairment, vision changes – – Cranial nerve palsy – – Headache, meningeal signs – – Altered mental signs • Predisposing factors – – Winter months (increased incidence of AVRS) – – Age Infant: highest risk of meningitis 3–6 years: highest rate of hospitaliza- tion for complication of ABRS 10–29 years: highest risk of intracranial complication • Teenage males likely to have simul- taneous orbital and intracranial complications • Orbital complications – – Most common complication of acute rhinosinusitis Due to two-way communication between ethmoid and ophthalmic venous plexuses Nasal obstruction Purulent rhinorrhea Facial pain/pressure Exam findings AVRS ABRS 5-10d course of ABX Topical steroids NSAIDs/analgesics Topical decongestant Saline irrigation Oral decongestants RARS Immune workup Imaging Other medical workup Middle meatal culture imaging Change ABX Imaging Admision and IV ABX Multidisciplinary consultation Suspected complication Treatment failure Lack of resolution Return to baseline Recurrent infection Shared decision- making 10d ≥10d “Watchful waiting” (up to 7d) “Double worsening” Fig. 23.1 ARS treatment algorithm M. Kim et al.
- 5. 257 • Valveless ophthalmic veins commu- nicate anteriorly with facial veins and posteriorly with cavernous sinus Periorbita is the only soft tissue barrier between orbit and sinonasal cavity • Fuses anteriorly with tarsal plates to form orbital septum Usually polymicrobial • Viridans streptococci and staphy- locci are most common organisms – – Chandler classification system of orbital complications I: Preseptal orbital cellulitis • Periorbital edema/erythema • No chemosis or ocular symptoms • Can occur in absence of sinusitis – – Infection of eyelid and orbital adnexa – – Trauma – – Foreign body II: Postseptal orbital cellulitis • Proptosis, chemosis, ophthalmoplegia • Can have decreased visual acuity later in disease course III: Orbital subperiosteal abscess • Symptoms similar to group II • Usually normal vision unless abscess very large IV: Orbital abscess • Symptoms similar to group III • Usually complete ophthalmoplegia and decrease in vision V: Cavernous sinus thrombosis • Symptoms similar to group IV • Additional involvement of V1 and V2 • Bilateral eye symptoms • Can have associated meningismus, frank meningitis, or sepsis – – Orbital apex syndrome Presents similar to cavernous sinus thrombosis with frank optic nerve involvement Trigeminal involvement would be lim- ited to V1 branches – – Superior orbital fissure (Rochon– Duvigneaud) syndrome Similar to orbital apex syndrome but spares optic nerve – – Evaluation Comprehensive ophthalmologic exam Imaging • CT is the gold standard – – IV contrast useful if concern for abscess or cavernous sinus thrombosis • MRI is better for cavernous sinus thrombosis – – Management Medical therapy—oral agents—is usu- ally sufficient (Chandler I–II) Intravenous antibiotics (Chandler II–V) • High-dose penicillin/beta-lacta- mase inhibitor (e.g., ampicillin/sul- bactam) or third-generation cephalosporin • Adjunct medications: systemic/topi- cal steroids and decongestants, saline irrigations, mucolytics Surgery (Chandler IV–V) • Subperiosteal abscess (III): size 2 cm and age 9 years more likely to require surgical intervention • Lack of improvement over 48–72 h on medical therapy alone also indica- tion for surgery • Lateral and superior abscesses likely require external orbitotomy Anticoagulation for cavernous sinus thrombosis is controversial • Thought to stop progression of thrombosis, decrease clot propaga- tion, and allow better antibiotic penetration • Risk includes systemic or intracra- nial hemorrhage and septic embolization • Frontal bone osteomyelitis with subperiosteal abscess (“Pott’s puffy tumor”) – – Suppurative infection of diploic veins – – Causes bone demineralization and necrosis – – Requires medical and surgical therapy Prolonged IV antibiotics for osteomyelitis 23 Acute Sinusitis and Its Complications
- 6. 258 • Intracranial complications – – More common in males and children 7 years – – CRS thought to increase risk due to chronic mucosal/bony changes that decrease muco- ciliary clearance and hinder antibiotic penetration Initial symptoms may not be character- istic of ARS • Persistent headache and fever are typical presenting complaints – – Mechanism: septic thrombophlebitis or direct bony extension (neurovascular foramina, congenital dehiscence, traumatic fracture) – – Microbiology Meningitis mostly due to Streptococcus pneumoniae Abscess often polymicrobial, including anaerobes – – May be asymptomatic until late in course due to involvement of non-eloquent frontal lobe Seizures, focal neurologic deficits are late findings and portend poor progno- sis Can present synchronously and in con- junction with orbital complications – – MRI with contrast is radiographic study of choice CT often also obtained for bony anat- omy and surgical planning – – Epidural abscess Most common intracranial complication Generally associated with frontal sinusitis • Headache, fever, orbital pain, frontal pain Favorable prognosis – – Subdural abscess Also usually a sequela of frontal sinusitis Usually unilateral Tendency to spread over cerebral cortex and into interhemispheric region Higher morbidity and mortality • Can have rapid progression – – Headaches, fever, letharg → coma • Meningismus and focal neurologic deficits – – Intracerebral abscess Less common Typically involves frontal and parietal lobes • Frontal sinusitis sphenoid/ethmoid sinusitis Fever, headache, lethargy, vomiting • Seizures, focal deficits are late findings • Can also have mood swings and behavioral changes Lumbar puncture contraindicated before imaging obtained • Risk of brain herniation – – Venous sinus thrombosis Sagittal sinus thrombosis can occur sec- ondary to frontal sinusitis Meningeal signs and significant neuro- logic complications Often in conjunction with other intra- cranial complications – – Meningitis Typically secondary to ethmoiditis or sphenoiditis Headache, neck stiffness, fever Can present with sepsis or cranial neuropathy Often in conjunction with other intra- cranial complications – – Management Broad-spectrum intravenous antibiotics with good intracranial penetration • Often 4–8 week course of antibiotics Systemic steroids and anticonvulsants Neurosurgical drainage usually indicated Sinus surgery to address culprit sinuses • Frontal sinus trephination can be useful adjunct to endoscopic techniques Repeat imaging critical to monitor treat- ment response and prior to discharge to ensure continued resolution without treatment escalation M. Kim et al.
- 7. 259 23.1.8 Recurrent Acute Rhinosinusitis • Predisposing factors – – Viral ARS – – Allergic rhinitis – – Immunodeficiency – – Anatomy (e.g., deviated nasal septum, con- cha bullosa) • Confirming true ABRS episodes is important – – Endoscopy reveals purulence during acute episode – – Imaging between episodes can confirm complete resolution and reveal anatomic anomalies • Management – – Immunologic testing Immunoglobulin deficiencies • Combined variable immunodefi- ciency (CVID) • IgA deficiency • Specific antibody deficiency – – Role of antibiotics and topical steroids lim- ited to use during ARS episodes – – Surgery may be beneficial in select patients Appropriateness criteria • ≥4 episodes per year • ARS confirmed by endoscopy or imaging • Shared decision-making • Failed trial of nasal steroid or loss of productivity Extent of surgery unclear • Addressing anatomic variants predis- posing to recurrent infection can be helpful – – Balloon sinuplasty may also be beneficial Less evidence than for ESS, for this indication Further Reading Clayman GL, Adams GL, Paugh DR, Koopmann CF Jr. Intracranial complications of paranasal sinus- itis: a combined institutional review. Laryngoscope. 1991;101(3):234–9. Fokkens WJ, Lund VJ, Hopkins C, et al. European posi- tion paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020;58(Suppl S29):1–464. Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(Suppl 1):S22–209. Peña MT, Preciado D, Orestes M, Choi S. Orbital com- plications of acute sinusitis: changes in the post- pneumococcal vaccine era. JAMA Otolaryngol Head Neck Surg. 2013;139(3):223–7. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC III, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical prac- tice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3 Suppl):S1–31. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinus- itis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1–S39. Take Home Messages • ARS can be characterized by causative pathogen (virus, bacteria, fungus). • Diagnosis is chiefly clinical. • Treatment depends on etiology and symptom duration. • Complications of ABRS warrant special attention. 23 Acute Sinusitis and Its Complications