Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3)

Clinical Manifestations Most cases of acute sinusitis present after or in conjunction with a viral URI, and it can be difficult to discriminate the clinical features of one from the other. A large proportion of patients with colds have sinus inflammation, although bacterial sinusitis complicates only 0.2–2% of these viral infections. Common presenting symptoms of sinusitis include nasal drainage and congestion, facial pain or pressure, and headache. Thick, purulent or discolored nasal discharge is often thought to indicate bacterial sinusitis but also occurs early in viral infections such as the common cold and is not specific to bacterial infection....
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Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3) Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3) Clinical Manifestations Most cases of acute sinusitis present after or in conjunction with a viralURI, and it can be difficult to discriminate the clinical features of one from theother. A large proportion of patients with colds have sinus inflammation, althoughbacterial sinusitis complicates only 0.2–2% of these viral infections. Commonpresenting symptoms of sinusitis include nasal drainage and congestion, facialpain or pressure, and headache. Thick, purulent or discolored nasal discharge isoften thought to indicate bacterial sinusitis but also occurs early in viral infectionssuch as the common cold and is not specific to bacterial infection. Othernonspecific manifestations include cough, sneezing, and fever. Tooth pain, mostoften involving the upper molars, is associated with bacterial sinusitis, as ishalitosis. In acute sinusitis, sinus pain or pressure often localizes to the involvedsinus (particularly the maxillary sinus) and can be worse when the patient bendsover or is supine. Although rare, manifestations of advanced sphenoid or ethmoidsinus infection can be profound, including severe frontal or retroorbital painradiating to the occiput, thrombosis of the cavernous sinus, and signs of orbitalcellulitis. Acute focal sinusitis is uncommon but should be considered in thepatient with severe symptoms over the maxillary sinus and fever, regardless ofillness duration. Similarly, advanced frontal sinusitis can present with a conditionknown as Potts puffy tumor, with soft tissue swelling and pitting edema over thefrontal bone from a communicating subperiosteal abscess. Life-threateningcomplications include meningitis, epidural abscess, and cerebral abscess. Patients with acute fungal sinusitis (such as mucormycosis) often presentwith symptoms related to pressure effects, particularly when the infection hasspread to the orbits and cavernous sinus. Signs such as orbital swelling andcellulitis, proptosis, ptosis, and decreased extraocular movement are common, asis retroorbital or periorbital pain. Nasopharyngeal ulcerations, epistaxis, andheadaches are also frequent, and involvement of cranial nerves V and VII has beendescribed in more advanced cases. Bony erosion may be evident on examination.Oftentimes, the patient does not appear seriously ill despite the rapidly progressivenature of these infections. Patients with acute nosocomial sinusitis are often critically ill and thus donot manifest the typical clinical features of sinus disease. This diagnosis should besuspected, however, when hospitalized patients who have appropriate risk factors(e.g., nasotracheal intubation) develop fever of unknown origin. Diagnosis Distinguishing viral from bacterial sinusitis in the ambulatory setting isusually difficult, given the relatively low sensitivity and specificity of the commonclinical features. One clinical feature that has been used to help guide diagnosticand therapeutic decision-making is illness duration. Because acute bacterialsinusitis is uncommon in patients whose symptoms have lasted 7 days in adults or >10–14 days in children)accompanied by purulent nasal discharge (Table 31-1). Even among the patientswho meet these criteria, only 40–50% have true bacterial sinusitis. The use of CTor sinus radiography is not recommended for routine cases, particularly early inthe course of illness (i.e., at Age Diagnostic Treatment RecommendationsaGroup Criteria Adults Moderate Initial therapy symptoms (e.g., nasal purulence/ congestion or cough) for >7 d or Severe symptoms Amoxicillin, 500 mg PO tid or of any duration, including 875 mg PO bid, or unilateral/focal facial swelling or tooth pain TMP-SMX, 1 DS tablet PO bid for 10–14 d Exposure to antibiotics within 30 d or >30% prevalence of penicillin- resistant S. pneumoniae Amoxicillin, 1000 mg PO tid,or Amoxicillin/clavulanate(extended release), 2000 mg PO bid, or Antipneumococcalfluoroquinolone (e.g., levofloxacin, 500mg PO qd) Recent treatment failure Amoxicillin/clavulanate(extended release), 2000 mg PO bid, or Amoxicillin, 1500 mg bid, plusclindamycin, 300 mg PO qid, or Antipneumococcalfluoroquinolone (e.g., levofloxacin, 500 mg PO qd)Children Moderate Initial therapy symptoms (e.g., nasal purulence/congestion or cough) for >10–14 d or Severe symptoms Amoxicillin, 45–90 mg/kg qd of any duration, including (up to 2 g) PO in divided doses (bid or fever (>102°F), tid), or unilateral/focal facial swelling or pain Cefuroxime axetil, 30 mg/kg qd PO in divided doses (bid), or Cefdinir, 14 mg/kg PO qd Exposure to antibiotics within ...