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Practice Parameters for the Diagnosis and Management of Sinusitis
The following summary was written by the
AAAAI Sinusitis Committee in 2002, based on the August 2001 parameters
Definitions
Sinusitis is defined as inflammation of one or more of the
paranasal sinuses. It is subclassified according to duration of symptoms and
frequency of recurrence.
- Acute sinusitis
- symptoms for 3-4 weeks consisting of any or all of
the following: persistent URI symptoms, purulent rhinorrhea, post nasal
drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, and
purulent mucus drainage.
- Chronic sinusitis
– same symptoms as acute sinusitis, of varying
severity, for 3-8 weeks or longer. In chronic sinusitis there should be
abnormal findings on CT or MRI.
- Recurrent sinusitis
– three or more episodes of acute sinusitis in a
year. Different infectious pathogens may be found at different times.
Anatomic considerations, sinus physiology, microbiology
Anatomic considerations – the sinuses develop at different
ages during childhood.
- The ethmoid bulla cells can occasionally enlarge into the middle
turbinate, causing pneumatization (concha bullosa), which can obstruct
ventilation of the middle meatus. Frontal recess cells can impinge upon the
nasofrontal duct. Blockage of the middle meatus or the nasofrontal duct can
lead to sinusitis.
- Nasal and sinus polyps can create obstruction in multiple locations that
can lead to sinusitis.
- Septal deviation can predispose to sinusitis if the deviation narrows the
middle meatus.
- Infection and tumors in the sphenoid sinuses can progress into the optic
nerve, cavernous sinus, carotid artery, and sella turcica.
Sinus physiology
– the sinuses are air-filled cavities with
pseudostratified ciliated columnar epithelium interspersed with goblet cells.
The cilia sweep mucus toward the ostial opening.
- Obstruction of the sinus ostia may lead to mucus impaction and decreased
oxygenation in the sinus cavities. During this obstruction, pressure in the
sinus cavity may decrease, which may lead to pain, particularly in the frontal
region.
Microbiology – predominant organisms vary according to the
duration of sinusitis and other considerations.
- Acute sinusitis:
viral URIs frequently precede bacterial
superinfection with Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis. All of these organisms may have significant
antibiotic resistance.
- Chronic sinusitis:
all the organisms mentioned above, as well as
Pseudomonas aeruginosa, Group A streptococcus, Staphylococcus aureus,
and anaerobes such as Bacteroides spp., Fusobacteria, and
Propionibacterium acnes.
- Nosocomial sinusitis:
gram negative enterics (such as P aeruginosa,
Klebsiella pneumoniae, Enterobacter spp, Proteus mirabilis, Serratia
marcescens) and gram positive cocci (occasionally streptococci and
staphylococci).
- Fungal sinusitis:
in immunocompetent individuals, the most common
cause of fungal sinusitis is Aspergillus fumigatus. Allergic fungal
sinusitis may be caused by Aspergillus spp, Myriodontium
keratinophilum, Bipolaris sp, Dreschlera sp, Curvularia spp,
and Aternaria spp. Fungal infection of the sinuses may manifest as
fungus "ball" in immunocompetent hosts and invasive fungal sinusitis in
imunocompromised hosts.
Diagnosis
Clinical history – acute sinusitis is typically first seen
as an upper respiratory infection that has persisted beyond 5-7 days.
- Factors that may predispose to sinusitis include allergic or occupational
rhinitis, vasomotor rhinitis, nasal polyps, rhinitis medicamentosa, and
immunodeficiency. For many patients, the clinical history should address these
factors.
Clinical examination –
- Symptoms:
nasal congestion, purulent rhinorrhea, postnasal drainage,
facial or dental pain, headache, hyposmia, and cough.
- Signs:
tenderness overlying the sinuses, mucosal erythema, nasal
purulent secretions, increased posterior pharyngeal secretions, and
periorbital edema.
- Transillumination may be useful if unilateral abnormalities are noted.
Imaging studies – imaging studies may be required when the
symptoms are vague, physical findings are equivocal, or there is poor response
to initial management.
- Standard radiographs (e.g., Water’s view) may be used for detection of
acute sinus disease, but are insensitive, especially in ethmoid disease.
- CT is the preferred imaging technique for evaluation of the nose and
paranasal sinuses. The preferred CT to obtain is limited numbers of coronal
sections, sometimes with added cuts through the osteomeatal complex, without
contrast.
- MRI has limitations in the definition of the bony anatomy, but is
particularly sensitive for evaluation of soft tissue differentiation as in
fungal sinusitis and tumors and in differentiating between inflammatory
disease and malignant tumors.
Laboratory tests
– laboratory tests are generally most
useful in the evaluation of underlying diseases.
- Quantitative sweat chloride tests for the diagnosis of cystic fibrosis
should be considered in children with nasal polyps and/or with proven
colonization of the nose or sinus with Pseudomonas spp.
- Tests for immunodeficiency (e.g., quantitative immunoglobulins, antibody
tests, serum IgE, complement components, HIV, and diabetes) may be useful if
either congenital or acquired immunodeficiency is suspected in cases of
recurrent sinusitis.
- Tests to screen for allergic fungal sinusitis (serum IgE) and
granulomatous diseases (e.g. ACE, ANCA, RPR) may be considered as well.
Other studies
- Fiberoptic rhinoscopy permits more detailed examination of nasal and
pharyngeal structures.
- Biopsy of the nose and paranasal sinuses may be useful to determine
whether a lesion is neoplastic, to confirm the presence of suspected fungal
disease or granulomatous disease, and to evaluate ciliary motility.
- Culture and stains of sinus material (from the middle meatus) for bacteria
and fungi may be useful to identify pathogens and assess antimicrobial
sensitivity.
Differential diagnosis
- The differential diagnosis of sinusitis includes cystic fibrosis,
granulomatous diseases, HIV infection, Kartagener’s syndrome, immotile cilia
syndrome, and tumors (such as nasopharyngeal angiofibroma).
Associated diseases
- Asthma: the association between sinusitis and asthma is generally stated
to range from 40% to 75% and the management of sinusitis often results in
improvement in asthma.
- Chronic rhinitis: allergic rhinitis and other forms of rhinitis (e.g.
vasomotor rhinitis and NARES) commonly precede the development of recurrent or
chronic sinusitis because of the retention of mucopurulent secretions within
the sinus cavities.
- Cystic fibrosis: chronic sinusitis is an important source of morbidity in
nearly all patients with cystic fibrosis, creating nasal obstruction, post
nasal drainage, headache, and potential exacerbation of pulmonary obstruction.
Treatment
Antibiotics – antibiotics are the primary therapy for
bacterial sinusitis.
- The most common bacteria observed are polysaccharide encapsulated
organisms of which 30% to 40% produce b -lactamase.
- Appropriate duration of therapy is not well defined for acute sinusitis,
but a 14-day course is probably adequate for most patients.
- Chronic sinusitis should be treated until the patient is well for 7 days
before stopping therapy.
- Choice of antibiotic should be based on predicted effectiveness, cost, and
side effects.
Antihistamines – there are no data presently to recommend
the use of antihistamines in acute bacterial sinusitis, but there may be a role
for these agents in chronic sinusitis, especially in patients with allergic
rhinitis. Furthermore, antihistamines are not detrimental to the treatment of
sinusitis.
α -Adrenergic decongestants – both topical and oral
decongestants are often used in the therapy of acute and chronic sinusitis, but
prospective studies are lacking.
Glucocorticosteroids
- The use of systemic steroid therapy for sinus disease has not been studied
in a well-controlled manner.
- Studies suggest that the addition of intranasal steroids as an adjunct to
antibiotic therapy is beneficial in the treatment of sinusitis.
Adjunctive therapies, including saline, mucolytics, and
expectorants
- There are inadequate data to recommend the use of wetting agents as
individual therapy for sinusitis.
- Clinical practice supports the use of wetting agents for symptomatic
treatment as part of a pharmacologic regimen.
- There are several studies that imply, but do not confirm, a role for these
agents in sinusitis.
- The use of all these agents as prophylaxis for exacerbations of chronic
sinusitis is empiric and not supported by clinical data.
Intravenous immune globulin – IVIG is indicated for use in
patients with documented impaired humoral immunity.
Allergen immunotherapy
– Allergic disease is often a major
contributor to the pathogenesis of chronic sinusitis. Allergen immunotherapy
often benefits patients with chronic sinusitis and documented allergies.
Surgical considerations
- Antral puncture and irrigation has a place in the management of acute
ethmo-maxillary sinusitis refractory to medical therapy or in an
immunosuppressed patient in whom early identification of pathogenic organisms
is paramount.
- Functional endoscopic sinus surgery is intended to relieve ostial
obstruction and to debride diseased tissue.
- Other surgical procedures that may have a place in the management of
chronic sinusitis include adenoidectomy, septoplasty, polypectomy, and
turbinate reduction.
When to Refer to an Allergist/Immunologist
- Allergists/immunologists have unique expertise in the evaluation and
medical management of sinonasal disorders. Accordingly, patients with chronic
or recurrent sinusitis, whose disease is poorly controlled or in whom the
nature and cause of the disease remains in question, should be referred to an
allergist/immunologist as the primary source of consultation. Furthermore,
patients with associated diseases, such as asthma, should be also referred to
an allergist/immunologist.
Where to go for Additional Resources
- The American Academy of Allergy, Asthma and Immunology (AAAAI) is the
premiere source of information about the pathophysiology and management of
sinusitis and related diseases. Resources may be obtained from the AAAAI
website (http://www.aaaai.org) or by calling (414) 272-6071. The AAAAI also
has contact information for allergists/immunologists in practice throughout
the world.
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