2015./2016.akad.gada LOR pulciņa 9.sēdes prezentācija "Acute rhinosinusitis". Autore Jana Kraķe (RSU MF III kursa studente).

1. Acute Rhinosinusitis
Autors:Jana Kraķe
MF3, 8.grupa
Mentors: Gints Tomiņš

2. Definition
1)“Rhinitis” is the inflammation of the nasal mucosa. It can be defined as
symptoms of nasal irritation, sneezing, rhinorrhoea and nasal blockage lasting for
at least 1 h a day on most days. The term “sinusitis” refers to inflammation of the
mucosa of the paranasal sinuses, regardless of the cause.
2)Acute rhinosinusitis is an inflammation of the paranasal sinuses and the nasal
cavity lasting no longer than 4 weeks. It can range from acute viral rhinitis (the
common cold) to acute bacterial rhinosinusitis.
Although sinusitis is the term commonly used for any inflammation or infection of sinuses,
this term has largely been replaced by rhinosinusitis, because the nose is almost always
involved with the infection or inflammation at the same time as the sinuses.

3. Classification of Rhinosinusitis
Acute - Up to four weeks
Subacute - At least four weeks but less than 12 weeks
Recurrent acute - Four or more episodes per year with complete
resolution between episodes,each episode lasts at least seven days
Chronic - 12 weeks or longer

4. Classification of Rhinosinusitis 2
 Localisation : maxillar sinus, sphenoidal sinus,
ethmoidal sinus, frontal sinus
 Infection: Bacterial/viral or fungal
 Morfology: exudative/productive
 Complication: orbital/intracranial

6. Predisposing factors for sinusitis
 Upper respiratory infections
 Anatomic variations
 Allergic rhinitis
 Nasal dryness
 Dental infections and procedures, trauma
 Barotrauma
 Hormone factors
 Immunodeficiency disease
 Inhalation of irritants
 Mechanical ventilation
 Nasotracheal and nasogastric tubes

7. CLINICAL FEATURES
Acute rhinosinusitis may be accompanied by low‐grade fever, malaise, headache and
possibly a cough.
Typical physical signs include bilateral nasal mucosal oedema, purulent nasal secretions and
sinus tenderness, although this is not a sensitive or specific finding. Pain on palpation over
the 1)frontal sinuses can indicate inflammation. 2)Maxillary sinus infection can cause
toothache with tenderness over the molar region. 3)Ethmoid sinusitis maybe associated with
swelling, tenderness and pain around the eyes.

8. Etiology
Most cases of acute rhinosinusitis are caused by viral infections associated with the common cold.
Mucosal edema leads to obstruction of the sinus ostia. In addition, viral and bacterial infections impair
the cilia, which transport mucus. The obstruction and slowed mucus transport cause stagnation of
secretions and lowered oxygen tension within the sinuses. This environment is an excellent culture
medium for viruses and bacteria.

9. Common causative organisms for acute
rhinosinusitis
Viruses
 Rhinovirus
 Influenza virus
 Parainfluenza virus
Bacteria
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 Anaerobic bacteria
 Staphylococcus aureus
 Streptococcus aureus
 Gram‐negative bacteria
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus

10. INVESTIGATIONS
 Acute rhinosinusitis is mainly a clinical diagnosis. More than 50% of patients
with sinus symptoms who visit primary care physicians are unlikely to have
bacterial sinusitis. The clinical diagnosis of acute bacterial sinusitis is most
appropriately made on the basis of the medical history, symptoms, and
clinical examination.

11.  Major criteria: nasal discharge, nasal blockage or
congestion, facial pain or pressure
 Minor criteria: headache, fever, tooth pain,
cough.
100% - 2 major and 1 minor criteria / 2 or more
minor criteria

12. Nasal cytology
 Sinus puncture (maxillary or frontal sinus) remains the gold standard for
obtaining sinus culture material, with many studies showing little correlation
between nasal swab and sinus culture.Nasal cytology (Hansel, Wright of Gram
stain) could be performed in cases of acute rhinosinusitis. Presence of
neutrophils and bacteria suggests bacterial rhinosinusitis.

13. Radiology
Radiology has traditionally been used as an investigative tool to diagnose acute
rhinosinusitis. This includes plain sinus radiographs and computed tomography
(CT) scans of the paranasal sinuses.
Vaters projection- we see maxillary sinus
Kaldvel projection-frontal sinus
Lateral projection- sphenoidal sinus,frontal sinus
Interesting fact- 40% of asymptomatic patients and 87% of patients with
community‐acquired colds have sinus abnormalities on sinus CT scan.

14. Treatment
Prescribe antibiotic therapy based on benefits and risks. Benefits depend on the
probability of bacterial infection and the severity of symptoms. Risks of
antibiotics include allergic reaction, potential side effects, and promotion of
bacterial resistance.
First line antibiotics for acute bacterial rhinosinusitis are amoxicillin and
trimethoprim/ sulfamethoxazole.(1000 mg 2x)
The usual initial course of antibiotics should be 10-14 days.
If symptoms worsen after 72 hours of initial empiric antimicrobial therapy, or
they fail to improve despite 3 to 5 days of initial empiric antimicrobial therapy, it
is reasonable to consider a change in medications.

15. Efficacy in symptom control: decongestants (especially
topical decongestants: xilometazolynum,
oxymetazolynum), topical anticholinergics and nasal
steroids (Beclometazonum,Budezonidum,Flutikazonum -
Eo, T ly,symptoms
Possible efficacy: zinc gluconate lozenges, vitamin C,
Echinacea extract, saline irrigation

16. SURGICAL MANAGEMENT
 Antral washout
 External frontoethmoidectomy
 Frontal sinus trephination
 Functional endoscopic sinus surgery

17. Complications of acute rhinosinusitis
 Preseptal cellulitis
 Orbital cellulitis
 Orbital abscess
 Osteomyelitis
 Subperiosteal orbital abscess
 Subdural empyema
 Epidural empyema
 Meningitis
 Brain abscess
 Cortical thrombophlebitis
 Cavernous/sagittal sinus thrombosis

18. Resaerch
 Systemic corticosteroid monotherapy for clinically diagnosed acute
rhinosinusitis: a randomized controlled trial
 Methods: We conducted a block-randomized, double-blind, placebo-
controlled clinical trial at 54 primary care practices (68 family physicians) in
the Netherlands between Dec. 30, 2008, and Apr. 28, 2011. Adult patients
with clinically diagnosed acute rhinosinusitis were randomly assigned to
receive either prednisolone 30 mg/d or placebo for 7 days and asked to
complete a symptom diary for 14 days. The primary outcome measure was the
proportion of patients with resolution of facial pain or pressure on day 7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

19.  Results:Of the 185 patients included in the trial (93 in the treatment group,
92 in the placebo group), 2 withdrew from the study and 9 were excluded
from the primary analysis because of incomplete symptom reporting. The
remaining 174 patients (88 in the treatment group, 86 in the placebo group)
were included in the intention-to-treat analysis. The proportions of patients
with resolution of facial pain or pressure on day 7 were 62.5% (55/88) in the
prednisolone group and 55.8% (48/86) in the placebo group (absolute risk
difference 6.7%, 95% confidence interval −7.9% to 21.2%). The groups were
similar with regard to the decrease over time in the proportion of patients
with total symptoms (combined symptoms of runny nose, postnasal discharge,
nasal congestion, cough and facial pain) and health-related quality of life.
Adverse events were mild and did not differ significantly between the groups
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

20. Prednisolone n =88 Placebo n = 86
Absolute risk difference, % (95% CI) Relative risk(95% CI)
Facial pain or pressure 62.5 (55/88) 55.8 (48/86) 6.7 (−7.9 to 21.2) 1.12 (0.87 to 1.44)
Severe facial pain or pressure 93.2 (82/88) 82.6 (71/86) 10.6 (1.0 to 20.2) 1.13 (1.01 to 1.26)
Nasal congestion 57.5 (50/87) 53.5 (46/86) 4.0 (−10.8 to 18.8) 1.07 (0.82 to 1.40)
Postnasal discharge 54.5 (48/88) 57.6 (49/85) −3.0 (−17.9 to 11.7) 0.95 (0.73 to
1.23)
Runny nose 69.3 (61/88) 58.1 (50/86) 11.2 (−3.0 to 25.3) 1.19 (0.95 to 1.50)
Cough 66.3 (57/86) 54.8 (46/84) 11.5 (−3.1 to 26.1) 1.21 (0.95 to 1.55)
Total symptoms 32.9 (28/85) 25.3 (21/83) 7.6 (−6.1 to 21.3) 1.30 (0.81 to 2.10)
Severe total symptoms 81.2 (69/85) 78.3 (65/83) 2.9 (−9.3 to 15.0) 1.04 (0.89 to 1.21)
4 of 5 total symptoms 44.7 (38/85) 39.8 (33/83) 5.0 (−10.0 to 19.9) 1.12 (0.79 to 1.60)
3 of 5 total symptoms 62.4 (53/85) 57.8 (48/83) 4.5 (−10.3 to 19.3) 1.08 (0.84 to 1.38)http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

21.  Interpretation:Systemic corticosteroid monotherapy had no clinically
relevant beneficial effects among patients with clinically diagnosed acute
rhinosinusitis.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/

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23. ???
Acute rhinosinusitis is an
inflammation of the paranasal
sinuses and the nasal cavity
lasting no longer than ...........

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Symptoms

25.  https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-
B9781455746965000464?scrollTo=%23hl0000329
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600057/
 http://www.med.umich.edu/1info/FHP/practiceguides/Rhino/rhino.pdf
 http://www.aafp.org/afp/2011/0501/p1057.html#sec-1
 http://www.doctus.lv/2015/4/akuts-rinosinusits-un-ta-parvaldiba#_=_
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470641/