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

Acute Sinusitis: TreatmentMost 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) 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 clinicalgrounds improve without antibiotic therapy. The preferred initial approach inpatients with mild to moderate symptoms of short duration is therapy aimed atfacilitating sinus drainage, such as oral and topical decongestants, nasal salinelavage, and—in patients with a history of chronic sinusitis or allergies—nasalglucocorticoids. Adult patients who do not improve after 7 days, children who donot improve after 10–14 days, and patients with more severe symptoms (regardlessof duration) should be treated with antibiotics (Table 31-1). Empirical therapyshould consist of the narrowest-spectrum agent active against the most commonbacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin.No clinical trials support the use of broad-spectrum agents for routine cases ofbacterial sinusitis, even in the current era of drug-resistant S. pneumoniae. Up to10% of patients do not respond to initial antimicrobial therapy; sinus aspirationand/or lavage by an otolaryngologist should be considered in these cases.Antibiotic prophylaxis to prevent episodes of recurrent acute bacterial sinusitis isnot recommended. Surgical intervention and IV antibiotic administration are usually reservedfor patients with severe disease or those with intracranial complications, such asabscess or orbital involvement. Immunocompromised patients with acute invasivefungal sinusitis usually require extensive surgical debridement and treatment withIV antifungal agents active against fungal hyphal forms, such as amphotericin B.Specific therapy should be individualized according to the fungal species and theindividual patients characteristics. Treatment of nosocomial sinusitis should begin with broad-spectrumantibiotics to cover common pathogens such as S. aureus and gram-negativebacilli. Therapy should then be tailored to the results of culture and susceptibilitytesting of sinus aspirates. Chronic Sinusitis Chronic sinusitis is characterized by symptoms of sinus inflammationlasting >12 weeks. This illness is most commonly associated with either bacteriaor fungi, and clinical cure in most cases is very difficult. Many patients haveundergone treatment with repeated courses of antibacterial agents and multiplesinus surgeries, increasing their risk of colonization with antibiotic-resistantpathogens and of surgical complications. Patients often suffer significantmorbidity, sometimes over many years. In chronic bacterial sinusitis , infection is thought to be due to theimpairment of mucociliary clearance from repeated infections rather than topersistent bacterial infection. However, the pathogenesis of this condition is poorlyunderstood. Although certain conditions (e.g., cystic fibrosis) can predisposepatients to chronic bacterial sinusitis, most patients with this infection do not haveobvious underlying conditions that result in the obstruction of sinus drainage, theimpairment of ciliary action, or immune dysfunction. Patients experience constantnasal congestion and sinus pressure, with intermittent periods of greater severity,which may persist for years. CT can be helpful in determining the extent ofdisease and the response to therapy. The management team should include anotolaryngologist to conduct endoscopic examinations and obtain tissue samples forhistologic examination and culture. Chronic fungal sinusitis is a disease of immunocompetent hosts and isusually noninvasive, although slowly progressive invasive disease is sometimesseen. Noninvasive disease, which is typically associated with hyaline molds suchas Aspergillus species and dematiaceous molds such as Curvularia or Bipolarisspecies, 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 surgeryis usually curative in these patients, with no need for antifungal therapy. Anotherform of disease presents with long-standing, often unilateral symptoms andopacification 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 wherebony erosion occurs. A third form of disease, known as allergic fungal sinusitis, isseen in patients with a history of nasal polyposis and asthma, who often have hadmultiple sinus surgeries. Patients with this condition produce a thick, eosinophilicmucus with the consistency of peanut butter that contains sparse fungal hyphae onhistologic examination. Patients often present with pansinusitis. Chronic Sinusitis: Treatment Treatment of chronic bacterial sinusitis can be challenging and consistsprimarily of repeated culture-guided courses of antibiotics, sometimes for 3–4weeks at a time; administration of intranasal glucocorticoids; and mechanicalirrigation of the sinus with sterile saline solution. When this management approachfails, sinus surgery may be indicated and sometimes provides significant, albeitshort-term, alleviation. Treatment of chronic fungal sinusitis consists of surgicalremoval of impacted mucus. Recurrence, unfortunately, is common.