Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 4)

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Acute Sinusitis: Treatment Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after 7 days, children who do not improve after 10–14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics (Table 31-1). ...

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Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 4) Acute Sinusitis: Treatment Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after 7 days, children who do not improve after 10–14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics (Table 31-1). Empirical therapy should consist of the narrowest-spectrum agent active against the most common bacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin. No clinical trials support the use of broad-spectrum agents for routine cases of bacterial sinusitis, even in the current era of drug-resistant S. pneumoniae. Up to
10% of patients do not respond to initial antimicrobial therapy; sinus aspiration and/or lavage by an otolaryngologist should be considered in these cases. Antibiotic prophylaxis to prevent episodes of recurrent acute bacterial sinusitis is not recommended. Surgical intervention and IV antibiotic administration are usually reserved for patients with severe disease or those with intracranial complications, such as abscess or orbital involvement. Immunocompromised patients with acute invasive fungal sinusitis usually require extensive surgical debridement and treatment with IV antifungal agents active against fungal hyphal forms, such as amphotericin B. Specific therapy should be individualized according to the fungal species and the individual patient's characteristics. Treatment of nosocomial sinusitis should begin with broad-spectrum antibiotics to cover common pathogens such as S. aureus and gram-negative bacilli. Therapy should then be tailored to the results of culture and susceptibility testing of sinus aspirates. Chronic Sinusitis Chronic sinusitis is characterized by symptoms of sinus inflammation lasting >12 weeks. This illness is most commonly associated with either bacteria
or fungi, and clinical cure in most cases is very difficult. Many patients have undergone treatment with repeated courses of antibacterial agents and multiple sinus surgeries, increasing their risk of colonization with antibiotic-resistant pathogens and of surgical complications. Patients often suffer significant morbidity, sometimes over many years. In chronic bacterial sinusitis , infection is thought to be due to the impairment of mucociliary clearance from repeated infections rather than to persistent bacterial infection. However, the pathogenesis of this condition is poorly understood. Although certain conditions (e.g., cystic fibrosis) can predispose patients to chronic bacterial sinusitis, most patients with this infection do not have obvious underlying conditions that result in the obstruction of sinus drainage, the impairment of ciliary action, or immune dysfunction. Patients experience constant nasal congestion and sinus pressure, with intermittent periods of greater severity, which may persist for years. CT can be helpful in determining the extent of disease and the response to therapy. The management team should include an otolaryngologist to conduct endoscopic examinations and obtain tissue samples for histologic examination and culture. Chronic fungal sinusitis is a disease of immunocompetent hosts and is usually noninvasive, although slowly progressive invasive disease is sometimes seen. Noninvasive disease, which is typically associated with hyaline molds such as Aspergillus species and dematiaceous molds such as Curvularia or Bipolaris
species, can present as a number of different scenarios. In mild, indolent disease, which usually occurs in the setting of repeated failures of antibacterial therapy, only nonspecific mucosal changes may be seen on sinus CT. Endoscopic surgery is usually curative in these patients, with no need for antifungal therapy. Another form of disease presents with long-standing, often unilateral symptoms and opacification of a single sinus on imaging studies as a result of a mycetoma (fungus ball) within the sinus. Treatment for this condition is also surgical, although systemic antifungal therapy may be warranted in the rare case where bony erosion occurs. A third form of disease, known as allergic fungal sinusitis, is seen in patients with a history of nasal polyposis and asthma, who often have had multiple sinus surgeries. Patients with this condition produce a thick, eosinophilic mucus with the consistency of peanut butter that contains sparse fungal hyphae on histologic examination. Patients often present with pansinusitis. Chronic Sinusitis: Treatment Treatment of chronic bacterial sinusitis can be challenging and consists primarily of repeated culture-guided courses of antibiotics, sometimes for 3–4 weeks at a time; administration of intranasal glucocorticoids; and mechanical irrigation of the sinus with sterile saline solution. When this management approach fails, sinus surgery may be indicated and sometimes provides significant, albeit short-term, alleviation. Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus. Recurrence, unfortunately, is common.