The clinician's view of sinusitis CHESTER T. STAFFORD. MD. Augusta, Georgia
Widespread underdlagnosls and Inadequate treatment of acute sinusitis may be Inferred from the prevalence of chronic sinusitis In the United States. Thus the otolaryngologists's role In the management of sinusitis goes beyond treatment of referred patients. It also Includes the responsibility to educate referring physicians In Improved diagnostic methods and earlier, more effective forms of therapy. While antral puncture Isthe sine qua non for determining specific diagnosis, standard radiographs and sound clinical judgment may offer practical alternatives. Early,aggressive antibiotic therapy (with ampicillin, amoxlclllln, amoxlclllln-ciavulanate potassium, or appropriate cephalosporlns), plus oral decongestants for symptomatic relief, provides therapeutic efficacy for acute sinusitis and should be considered the Initial step toward prevention of chronic sinusitis. (OTOLARYNGOL HEAD NECK SURG 1990;103:870,)
Sinusitis is one of the most frequently overlooked diseases in clinical practice. Development of sinusitis in children may often not be considered by busy primary care practitioners because "all kids have runny noses." In adults, "a cold" may be presumed to be the cause of a patient's nasal congestion and associated symptoms. Sinusitis is also among the most misunderstood of the common respiratory diseases. Even when recognized. acute sinusitis is often inappropriately treatedwith antihistamines, which can cause excessive dryness of mucous membranes and may thicken secretionsand/ or with abbreviated courses of antibiotics that may alleviate immediate symptoms, but do not completely eradicate the infection within the closed sinus cavities. Inadequate treatment of acute sinusitis appears to often result in the development of chronic sinusitis, which is even less well understood and may be even less adequately treated.
Clinical Cluel to SlnulltIl The signs and symptoms of sinusitis are quite variable and are often nonspecific. Many patients simply state, "Doctor, I've got a sinus condition." Initial attempts at history-taking may yield no more than symptoms suggestive of a common cold, an int1uenza-like illness. or allergic rhinitis. Many busy physicians tend to settle for one of these diagnoses without considering the possibility of sinusitis. The first firm diagnostic clues to sinusitis may come from the physical examination, accompanied by detailed history-taking. Facial tenderness and pain accom-
23/0/24795
panying nasal congestion and purulent nasal discharge are common manifestations of acute sinus infection. Other manifested signs and symptoms may include anosmia, pain upon mastication, and halitosis. If an upper respiratory infection is not immediately evident. a recent history of one can often be elicited. Fever is found in about 50% of adults and 60% of children. I Headache is a common feature of sinusitis in adults, but occurs less frequently in children. Frequent tearing and edema of the eyelids suggest ethmoid disease; however, inflammatory edema can mask orbital cellulitis or abscess or both, and these should be considered in the differential diagnosis. In allergic children. sinusitis should be suspected if a patient has a sore throat. thick nasal discharge, and nighttime cough. Increased numbers of polymorphonuclear leukocytes demonstrated on a nasal smear may heighten the index of suspicion. General symptoms of headache, facial pain, and fever are often of minimal value in the diagnosis of sinusitis. Relying on a constellation of symptoms to confirm a diagnosis of sinusitis can only result in underdiagnosis because even the most common symptoms may be absent. Furthermore, elevations of the white blood cell count with shift of the differential cell count, increased erythrocyte sedimentation rate, and elevated serum immunoglobulin E levels are of little value in the diagnosis of sinusitis.
Acute Versul Chronic Sinulltil How, then, does one distinguish between acute and chronic sinusitis? By Kern's definition." acute suppurative sinusitis is any infectious process in a paranasal sinus lasting from I day to 3 weeks. Accurate description of a patient's sinusitis includes the name and the
870
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 5 Part 2 November 1990
Clinician's view of sinusitis 871
location (either right or left or bilateral) of the affected sinus. And when all or several of the sinuses-including the ethmoid, frontal, maxillary, and sphenoid Sinuses-are involved, the condition is classified as pansinusitis. Kern" further defines subacute sinusitis as a sinus infection lasting from 3 weeks to 3 months, during Which period epithelial damage in the sinuses may be reversible. After 3 months, however, the disease becomes chronic and may involve irreversible mucosal damage, requiring surgery for sinus ventilation and drainage. Acute sinusitis, in tum, can be superimposed On chronic disease. Diagnostic Measure. Transillumination, imaging techniques, and cytologic examination are office procedures commonly used to assist in the diagnosis of sinusitis. While some of these techniques are useful, all have inherent limitations. Transillumination. This traditional first step in demonstrating acute sinusitis has lost favor with many physicians because of its relatively low sensitivity and specificity, particularly in patients with high bone density Or with hypoplasia of the sinuses. Nevertheless, transillumination may occasionally provide useful information and should remain part of the physical examination of the patient who is suspected of having Sinusitis. Absent transmission of light through the maxillary or frontal sinuses or both (from a strong point light source in a dark room) indicates the need for further evaluation with more sophisticated diagnostic techniques, as has been discussed earlier. Total opacification suggests that antral puncture will probably yield positive culture results for the specific organism causing the sinusitis. I Good visualization of light on both sides reduces the possibility of obstruction of the sinuses by thickened fluid or of hypoplasia of the sinuses, which actually is not an uncommon finding. Transillumination probably contributes little to the evaluation by physicians who perform state-of-the-art fiberoptic rhinoscopy. For physicians who rely on less sophisticated technology, however, it can indicate the need for referral for further evaluation. Imaging technique.. Dr. Zinreich has described imaging techniques in detail in this symposium. One of the most useful diagnostic procedures is nasal endoscopy, which is becoming a part of the routine examination of the nose and throat. In our hospital, we recently invited an expert endoscopist to train our residents, fellows, and other physicians providing primary care to patients with sinusitis. Routinely, our otolar-
yngology section is training not only ENT residents, but our allergy fellows in these techniques. You have heard that plain radiographs have limited value, but occasionally a good Waters view, Caldwell view, and lateral views can yield useful information. These, of the many views that are available, appear to be the best radiographic views for most of the primary care physicians who are attempting to diagnose acute sinusitis in the office setting. Computed tomography (CT) is, of course, far superior to ordinary radiography, but in our hospital a CT scan of the sinuses costs approximately $400 compared with about $65 for a good set of sinus x-ray films. Ultrasonography. Its lower sensitivity and specificity compared with sinus radiographs has made ultrasonography less popular with many physicians. This technique may be useful, however, for follow-up in patients who are pregnant, or perhaps under other circumstances in which radiation exposure is contraindicated. In those situations, ultrasound appears to be capable of at least detecting fluid or cysts within the sinus cavities, although it does have a very poor record in terms of sensitivity and specificity for detecting mucosal thickening. Cytologic examination. Nasal swabs of purulent secretions taken from the ostia under the middle nasal turbinate, if plated at the patient's bedside, may yield some important clues to the identity of specific pathogens. Normal flora of the nose are believed to grow faster than sinus pathogens, as has been suggested by MacKay. 3 This observation may explain why specimens transported to a central bacteriology laboratory for culture may yield useless information. Cultures of specimens collected by antral puncture usually provide a definitive diagnosis, but this is seldom indicated in firstline primary care. Allergists generally perform microscopic examinations of nasal smears collected from most patients being evaluated for upper respiratory disorders. An abundance of eosinophils is generally considered indicative of an underlying allergy. However, a preponderance of polymorphonuclear cells is found in patients with sinus infections, including those with an underlying respiratory allergy, as has been demonstrated by Rachelefsky et al." Nasal cytology, however, should not be considered an alternative to sinus imaging in the initial evaluation of a patient with allergic rhinitis concomitant with sinusitis. ~
Management Goal. There is a need recognized by this national educational program to view sinusitis as a serious, debilitating disease that warrants precise diagnosis and specific ef-
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
.72
otoIaryngolOGYHead and Neck surgery
STAFFORD
Table 1. Efficacy of selected antimicrobial agents for the common pathogens In acute sinusitis· Pathogen
Recommended doaage: adult (chHdren)
Streplococcu'
H"emophllu.
~onJae
(30)t
InftUtmzae (20)t
Ampicillin
500 mg (60 mg/kg) q6h
+
Amoxicillin
500 mg (60 mg/kg) q8h
AmoxiciUinclavulanate potassium (500/125)
MOfOxell" c"t"ttholJl
Strepfococcu. pYtJf1fll*
St"phylocOCCUl
(20)t
«5)t
«5)t
±
±
+
±
+
±
±
+
:t:
1 tablet q8h (40 mg/kg/day in 3 divided doses)
+
+
+
+
+
Cefaclor
500 mg q6h (40-60 mg/kg q8h)
+
+
:t:
+
+
Cefuroxime axelil
250 mg q12h (125 mg q12h)
Erythromycin and sulfisoxazole
(50 mg/kg erythro-
+
+
+
+
+
+
+
+
Antimicrobial ag'"
Trimethoprim/sulfamelhoxazole (160/800)
mycin, 150 mg/kg sulfisoxazole q6h) 1 OS tablet q12h (5-20 ml susp q12h)
aUffIUI
+
+. Effective; ±. effective forstrains notproducing ~-Iactamase; -. noteffective. 'Based on available datafrom clinical trials and laboratory studies. tPercentage of cases of acute sinusitis caused by this pathogen.
fective therapy. Because this disease may have been so widely overlooked and misunderstood. it is important for physicians to base treatment on a rational medical approach. One way to assure effective therapy for patients with sinusitis is to think about the effect that a potential therapy may have on the ostiomeatal complex. Will the therapy control infection and/or relieve obstruction? Any effective approach should encompass these goals. Management goals for treatment of sinusitis include the following: I. Control of infection 2. Reduction of tissue edema 3. Facilitation of drainage 4. Maintenance of patency of the sinus ostia
Antlblotlo Therapy The primary goal of antibiotic therapy is to control infection in the closed sinus cavities, but the other therapeutic goals for sinusitis management should also be kept in mind. Reduction of tissue edema. normalization of gas exchange. and sinus drainage are necessary for restoration of normal physiologic function of the si-
nuses. Maintenance of ostial patency is also essential for clearing infection and preventing chronicity and recurrent acute attacks. The unreliability of cultures of secretions obtained by nasal swab dictates empiric antibiotic therapy directed at the most common pathogens. Antral puncture with aspiration is not usually indicated before the patient is initially treated with antibiotics. In fact. otolaryngologists generally prefer that patients be receiving antibiotic therapy before antral puncture is performed. Antibiotic protocol. Drs. Winther and Gwaltney will present the bacteriology of acute sinus infection and antibiotic selection in depth. From the clinician's viewpoint. however. it is essential to have a predetermined rationale for choice of appropriate antimicrobial agents. The first-line drugs of choice for treatment of acute sinusitis are ampicillin (500 mg every 6 hours for 14 days), or amoxicillin (500 mg every 8 hours for 14 days), Either should be effective against all likely bacteria except Staphylococcus aureus, ~-lactamase producing Haemophilus injluenzae and Moraxella catarrhalis, some anaerobes, and many gram-negative
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VOlume 103 Number 5 Part2
November 1990
Clinician's vfew of sfnusltts 171
Table 2. Sinusitis therapy: Selection based on therapeutic goals
-
AcftOlll
Antibiotics Decongestants
Topical steroids Mucoevacuants
Amoxicillin/trimethoprimsulfamethoxazole Phenylpropanolamine (PPA) Phenylephrine Oxymetazoline Beclomethasone dipropionate Flunisolide Guaifenesin Potassium iodide
Treats infection Increases ostial diameter Facilitates drainage Reduces inflammation Reduces mucous secretion Thins secretions Aids drainage
NOTE, The role of antihistamines has not been established in the treatment of acute sinusitis.
aerobic bacilli. A 2-week course of effective antibiotic therapy is considered adequate for acute sinusitis, but 3 or 4 weeks-or longer-may be necessary for adequate control of chronic sinus infection. For patients who are allergic to penicillin, trimethoprim (160 mg)/sulfamethoxazole (800 mg, one tablet twice daily) (TMP/SMX), is the alternative drug of choice,6 especially in areas with a high incidence of ~-lactamase-producing H. influenzae, which, along with pneumococci, are no longer uniformly sensitive to tetracycline. When patients fail to respond to ampicillin or amoxicillin alone, the combination of amoxicillin and clavulanate potassium (500 mg, one tablet every 8 hours) is likely to be effective. This combination is effective against S. aureus and ~-lactamase-producing strains of H. influenzae and M. catarrhalis, In children, the combination of erythromycin and SUlfisoxazole is often considered the treatment of choice, For patients ill enough to require hospitalization, a second-generation cephalosporin such as cefuroximeshouldbe given. Other cephalosporins may provide inadequate sinus fluid levels to be effectiveagainst many common pathogens." The recommended doses for adults and children, as well as the reported clinical efficacy of the antibiotics mentioned in this section, are summarized in Table I. Aaeulng real coat•. Cost effectiveness must always be a consideration, and the cost of recommended antibiotics varies greatly. For example, in our hospital the wholesale drug cost of 10 days of therapy with amoxicilJin, ampicillin, or TMP/SMX is less than $6, compared with about $21 for amoxicillin-clavulanate, about $27.50 for cefaclor, and $32 for erythromycin. Physicians,patients, andthird-party payersalike should understand, however, that even a $100 basic drug cost for an extended course of an effective antibiotic, along
with an appropriate decongestant, could save many times that amount in future examinations and treatment of chronic sinusitis-not to mention the savings in pain and inconvenience to our patients. Decongestant Therap.y l
There are several goals of decongestant therapy. They include the reduction of tissue edema, facilitation of drainage, and maintenance of the patency of the sinus ostia. In short, decongestants are necessary to meet the management goals for acute sinusitis. ' Basically, decongestants are available in two forms: topicaland systemicfor oral administration. Each agent differs slightly in its mechanisms of action (Table 2). Topical agent.. Locally active vasoconstrictor agents provide almost immediatesymptomatic relief by shrinkingthe inflamed and swollen nasal mucosa, Phenylephrine HCl nasal spray 0.5% and oxymetazoline HCI nasal spray 0.05% are topical decongestants frequently used in treatment of acute sinusitis in adults. Phenylephrine spray should be self-administered with the head in the upright position three or four times daily for 3 days, and no longer than a week. Oxymetazoline nasal spray should also be administered with the head erect, two or three sprays in each nostril two or three times daily, for no longer than 3 to 4 days. Use of either agent for longer than recommended periods or with more frequent applications entails a high risk of rebound vasodilatation. Oral systemic agent.. When decongestion is necessary for longer than 3 days, an oral syS#Cmic agent such as phenylpropanolamine (PPA) or pseudoephedrine is preferred. Oral decongestants are aadrenergic agonists that reduce nasal blood flow. Theoretically, these oral systemic agents have the potential to act on tissuesdeep in the ostiomeatalcomplex, where topical agents may not penetrate effectively. Roth
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OtolaryngologVHead and Neck Surgery
.74 STAFFORD
et al. 8 have demonstrated that systemic decongestants, CONCLUSION like topical agents, improve nasal airway patency. The Early diagnosis and early, aggressive antibiotic therefficacy of topical preparations may diminish after sevapy may reduce patient suffering and save a sizable eral days of treatment. This does not occur with the proportion of health care dollars spent on treatment of oral systemic formulations. Melen et al. 9 demonstrated sinusitis. From hospital medical records, orders for rathat PPA increases the functional diameter of the rnax-x-- diography, and pharmacists' records of prescriptions iIIary ostium. Oral decongestants are also available in filled, we believe that early diagnosis and early effective combination with mucoevacuants, such as guaifenesin, therapy are the exceptions rather than the rule. Only that may help to thin secretions and facilitate drainage. with an increased index of suspicion of the probability PPA and pseudoephedrine are generally considered of acute sinusitis can we effectively reverse these equally safe and effective as oral decongestants. In the trends. past, some clinicians had expressed concern about PPA producing or potentiating hypertension or other central REFERENCES nervous system stimulant responses. However, a num1. Gwaltney J Jr. Diagnostic and medical management of acute sinusitis. Presentation at The American Academy of Allergy and ber of controlled clinical studies have supported the Immunology. San Antonio. Texas, Feb. 5, 1989. overall' safety of PPA when taken at appropriate doses 2. Kern EB. Sinusitis. J Allergy Clin Immunol 1984;73:25-31. in approved dosage form.!":!' Additionally, concerns 3. MacKay ON. Antibiotic treatment of rhinitis and sinusitis. Am over the possibility that PPA might raise blood pressures J Rhinol 1987;1:83-5. significantly were addressed recently by Kroenke 4. Rachelefsky GS. Katz RM. Siegel SC. Chronic sinusitis in children with respiratory allergy: the role of antimicrobials. J Allergy et a1. , 14 who concluded that PPA affects blood pressure Clin Immunol 1982;69:382-7. no more than does placebo, in patients with stable hyS. Gill FF. Neiburger JB. The role of nasal cytology in the diagnosis pertension. of chronic sinusitis. Am J Rhinology 1989;3:13-5. Antihistamines have not proved to be effective in the 6. Hamory BH. Sande MA, Sydnor A Jr, Seale DL, Gwaltney JM management of acute sinusitis and are not usually inJr. Etiology and antimicrobial therapy of acute maxillary sinusitis. J Infect Dis 1979;139:197-202. dicated as symptomatic or adjunctive therapy. Because 7. Malow JB, Creticos CM. Nonsurgical treatment of sinusitis. of their anticholinergic action, classic antihistamines Otolaryngol Clin North Am 1989;22:809-18. can cause dryness of mucous membranes and may in8. Roth RP, Cantekin VI. Bluestone CD. Nasal decongestant acterfere with the clearance of purulent mucous secretivity of pseudoephedrine. Ann Otol Rhinol Laryngol 1987; tions. Even the newer, nonsedating antihistamines that 86:235-41. 9. Melen 1. Friberg B. Andreasson L, et al. Effects of phenylprohave no significant anticholinergic effects have no role panolamine on ostial and nasal patency in patients treated for in the treatment of most patients with acute sinusitis. chronic maxillary sinusitis. Acta Otolaryngol 1986;10I:494-500. The appropriate role of antihistamines is for treatment 10. Goodman RP, Wright JT, Barlascini CO. et al. The effect of of allergic manifestations. Antihistamines are indicated phenylpropanolamine on ambulatory blood pressure. Clin Pharonly when patients manifest profuse, thin, watery rhimacol Ther 1986;40:144-7. II. Liebson 1, Bigelow G, Griffiths RR, Funderburk FP. Phenylnorrhea, sneezing, and pruritus.
Indloatlons tor Follow-up If antibiotic therapy initiated on the day of diagnosis for acute sinusitis has not provided adequate relief of symptoms after 7 days, a 10- to 14-day course of therapy should be prescribed with another antibiotic with a broader spectrum of sensitivity." If symptoms persist after 21 days of antibiotic therapy, referral for more definitive studies is probably indicated. Failure of appropriate antibiotic therapy suggests that the patient's sinusitis has extended beyond the acute stage. Failure of ampicillin or amoxicillin, followed by failure of the amoxicillin-clavulanate combination, suggests the possibility of an unusual pathogen or an anatomic abnormality. Endoscopic nasal surgery may be necessary to reopen and maintain the patency of the sinus ostia and ostiomeatal channels to allow healing.
12.
13.
14.
15.
propanolamine: effects on subjective and cardiovascular variables at recommended over-the-counter dose levels. J Clin Pharmacol 1987;27:685-93. Silverman HI. Kreger BE, Lewis GP. Lack of side effects from orally administered phenylpropanolamine and phenylpropanolamine with caffeine: II controlled three phase study. Curr Ther Res 1980;28:185-94. Blackburn GL, Morgan JP, Lavin PT, Noble R, Funderburk FR, lstfan N. Determinants of the pressor effect of phenylpropanolamine in healthy subjects. JAMA 1989;261:3267-72. Kroenke K. Omori OM, Simmons 10, Wood DR, Meier NJ. The safely of phenylpropanolamine in patients with stable hypertension. Ann Intern Med 1989;111:1043-4. Reilly J5, Kenna MA. Managing the spectrum of childhood sinusitis. J Respir Dis 1987;8:75-85.
DISCUSSION Dr. Kennedy: In regard to your citation of Dr. Kern' s classification of sinus disease, I believe his position was
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Volume 103 Number 5 Part 2 November 1990
Clinician's view of sinusitis .71
that mucosal disease in chronic sinusitis becomes irreversible after 3 months. That does not seem to be the case; with good ventilation and drainage, mucosal damage may reverse over time. Dr. Stafford: We now have better methods of visualizing the mucosa than Dr. Kern had. Dr. Kennedy: Exactly. And I support your defense of transillumination as a useful diagnostic tool. Transillumination provides similar information to ultrasonography. Ultrasonography is difficult to do and has highly variable results, and provides no information about the ethmoid sinus. Although failure of a sinus to transilluminate does not confirm sinusitis, it still provides useful information; opacity could occur because of a small hypoplastic sinus. If a sinus does illuminate, symptoms could be the result of a cyst within the sinus or minor mucosal thickening. This is useful information.
Now, with regard to the use of topical or systemic corticosteroids as second-line therapy, will you discuss your approach to both acute and chronic sinusitis? Dr. Stafford: When a patient with acute sinusitis has a closed-off cavity, we prefer to use topical vasoconstrictor drugs long enough to open the ostia. We feel that antiinflammatory topical corticosteroids then help maintain patency. Dr. Druce: Though many physicians are concerned that corticosteroids might exacerbate sinus infection, this does not seem to be the case when antibiotics are being administered. However, I know of no reason to use systemic corticosteroids in therapy for acute or chronic sinusitis, unless the patient also has a systemic condition that warrants their use.
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Widespread underdlagnosls and Inadequate treatment of acute sinusitis may be Inferred from the prevalence of chronic sinusitis In the United States. Thus the otolaryngologists's role In the management of sinusitis goes beyond treatment of referred patients. It also Includes the responsibility to educate referring physicians In Improved diagnostic methods and earlier, more effective forms of therapy. While antral puncture Isthe sine qua non for determining specific diagnosis, standard radiographs and sound clinical judgment may offer practical alternatives. Early,aggressive antibiotic therapy (with ampicillin, amoxlclllln, amoxlclllln-ciavulanate potassium, or appropriate cephalosporlns), plus oral decongestants for symptomatic relief, provides therapeutic efficacy for acute sinusitis and should be considered the Initial step toward prevention of chronic sinusitis. (OTOLARYNGOL HEAD NECK SURG 1990;103:870,)
Sinusitis is one of the most frequently overlooked diseases in clinical practice. Development of sinusitis in children may often not be considered by busy primary care practitioners because "all kids have runny noses." In adults, "a cold" may be presumed to be the cause of a patient's nasal congestion and associated symptoms. Sinusitis is also among the most misunderstood of the common respiratory diseases. Even when recognized. acute sinusitis is often inappropriately treatedwith antihistamines, which can cause excessive dryness of mucous membranes and may thicken secretionsand/ or with abbreviated courses of antibiotics that may alleviate immediate symptoms, but do not completely eradicate the infection within the closed sinus cavities. Inadequate treatment of acute sinusitis appears to often result in the development of chronic sinusitis, which is even less well understood and may be even less adequately treated.
Clinical Cluel to SlnulltIl The signs and symptoms of sinusitis are quite variable and are often nonspecific. Many patients simply state, "Doctor, I've got a sinus condition." Initial attempts at history-taking may yield no more than symptoms suggestive of a common cold, an int1uenza-like illness. or allergic rhinitis. Many busy physicians tend to settle for one of these diagnoses without considering the possibility of sinusitis. The first firm diagnostic clues to sinusitis may come from the physical examination, accompanied by detailed history-taking. Facial tenderness and pain accom-
23/0/24795
panying nasal congestion and purulent nasal discharge are common manifestations of acute sinus infection. Other manifested signs and symptoms may include anosmia, pain upon mastication, and halitosis. If an upper respiratory infection is not immediately evident. a recent history of one can often be elicited. Fever is found in about 50% of adults and 60% of children. I Headache is a common feature of sinusitis in adults, but occurs less frequently in children. Frequent tearing and edema of the eyelids suggest ethmoid disease; however, inflammatory edema can mask orbital cellulitis or abscess or both, and these should be considered in the differential diagnosis. In allergic children. sinusitis should be suspected if a patient has a sore throat. thick nasal discharge, and nighttime cough. Increased numbers of polymorphonuclear leukocytes demonstrated on a nasal smear may heighten the index of suspicion. General symptoms of headache, facial pain, and fever are often of minimal value in the diagnosis of sinusitis. Relying on a constellation of symptoms to confirm a diagnosis of sinusitis can only result in underdiagnosis because even the most common symptoms may be absent. Furthermore, elevations of the white blood cell count with shift of the differential cell count, increased erythrocyte sedimentation rate, and elevated serum immunoglobulin E levels are of little value in the diagnosis of sinusitis.
Acute Versul Chronic Sinulltil How, then, does one distinguish between acute and chronic sinusitis? By Kern's definition." acute suppurative sinusitis is any infectious process in a paranasal sinus lasting from I day to 3 weeks. Accurate description of a patient's sinusitis includes the name and the
870
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 5 Part 2 November 1990
Clinician's view of sinusitis 871
location (either right or left or bilateral) of the affected sinus. And when all or several of the sinuses-including the ethmoid, frontal, maxillary, and sphenoid Sinuses-are involved, the condition is classified as pansinusitis. Kern" further defines subacute sinusitis as a sinus infection lasting from 3 weeks to 3 months, during Which period epithelial damage in the sinuses may be reversible. After 3 months, however, the disease becomes chronic and may involve irreversible mucosal damage, requiring surgery for sinus ventilation and drainage. Acute sinusitis, in tum, can be superimposed On chronic disease. Diagnostic Measure. Transillumination, imaging techniques, and cytologic examination are office procedures commonly used to assist in the diagnosis of sinusitis. While some of these techniques are useful, all have inherent limitations. Transillumination. This traditional first step in demonstrating acute sinusitis has lost favor with many physicians because of its relatively low sensitivity and specificity, particularly in patients with high bone density Or with hypoplasia of the sinuses. Nevertheless, transillumination may occasionally provide useful information and should remain part of the physical examination of the patient who is suspected of having Sinusitis. Absent transmission of light through the maxillary or frontal sinuses or both (from a strong point light source in a dark room) indicates the need for further evaluation with more sophisticated diagnostic techniques, as has been discussed earlier. Total opacification suggests that antral puncture will probably yield positive culture results for the specific organism causing the sinusitis. I Good visualization of light on both sides reduces the possibility of obstruction of the sinuses by thickened fluid or of hypoplasia of the sinuses, which actually is not an uncommon finding. Transillumination probably contributes little to the evaluation by physicians who perform state-of-the-art fiberoptic rhinoscopy. For physicians who rely on less sophisticated technology, however, it can indicate the need for referral for further evaluation. Imaging technique.. Dr. Zinreich has described imaging techniques in detail in this symposium. One of the most useful diagnostic procedures is nasal endoscopy, which is becoming a part of the routine examination of the nose and throat. In our hospital, we recently invited an expert endoscopist to train our residents, fellows, and other physicians providing primary care to patients with sinusitis. Routinely, our otolar-
yngology section is training not only ENT residents, but our allergy fellows in these techniques. You have heard that plain radiographs have limited value, but occasionally a good Waters view, Caldwell view, and lateral views can yield useful information. These, of the many views that are available, appear to be the best radiographic views for most of the primary care physicians who are attempting to diagnose acute sinusitis in the office setting. Computed tomography (CT) is, of course, far superior to ordinary radiography, but in our hospital a CT scan of the sinuses costs approximately $400 compared with about $65 for a good set of sinus x-ray films. Ultrasonography. Its lower sensitivity and specificity compared with sinus radiographs has made ultrasonography less popular with many physicians. This technique may be useful, however, for follow-up in patients who are pregnant, or perhaps under other circumstances in which radiation exposure is contraindicated. In those situations, ultrasound appears to be capable of at least detecting fluid or cysts within the sinus cavities, although it does have a very poor record in terms of sensitivity and specificity for detecting mucosal thickening. Cytologic examination. Nasal swabs of purulent secretions taken from the ostia under the middle nasal turbinate, if plated at the patient's bedside, may yield some important clues to the identity of specific pathogens. Normal flora of the nose are believed to grow faster than sinus pathogens, as has been suggested by MacKay. 3 This observation may explain why specimens transported to a central bacteriology laboratory for culture may yield useless information. Cultures of specimens collected by antral puncture usually provide a definitive diagnosis, but this is seldom indicated in firstline primary care. Allergists generally perform microscopic examinations of nasal smears collected from most patients being evaluated for upper respiratory disorders. An abundance of eosinophils is generally considered indicative of an underlying allergy. However, a preponderance of polymorphonuclear cells is found in patients with sinus infections, including those with an underlying respiratory allergy, as has been demonstrated by Rachelefsky et al." Nasal cytology, however, should not be considered an alternative to sinus imaging in the initial evaluation of a patient with allergic rhinitis concomitant with sinusitis. ~
Management Goal. There is a need recognized by this national educational program to view sinusitis as a serious, debilitating disease that warrants precise diagnosis and specific ef-
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
.72
otoIaryngolOGYHead and Neck surgery
STAFFORD
Table 1. Efficacy of selected antimicrobial agents for the common pathogens In acute sinusitis· Pathogen
Recommended doaage: adult (chHdren)
Streplococcu'
H"emophllu.
~onJae
(30)t
InftUtmzae (20)t
Ampicillin
500 mg (60 mg/kg) q6h
+
Amoxicillin
500 mg (60 mg/kg) q8h
AmoxiciUinclavulanate potassium (500/125)
MOfOxell" c"t"ttholJl
Strepfococcu. pYtJf1fll*
St"phylocOCCUl
(20)t
«5)t
«5)t
±
±
+
±
+
±
±
+
:t:
1 tablet q8h (40 mg/kg/day in 3 divided doses)
+
+
+
+
+
Cefaclor
500 mg q6h (40-60 mg/kg q8h)
+
+
:t:
+
+
Cefuroxime axelil
250 mg q12h (125 mg q12h)
Erythromycin and sulfisoxazole
(50 mg/kg erythro-
+
+
+
+
+
+
+
+
Antimicrobial ag'"
Trimethoprim/sulfamelhoxazole (160/800)
mycin, 150 mg/kg sulfisoxazole q6h) 1 OS tablet q12h (5-20 ml susp q12h)
aUffIUI
+
+. Effective; ±. effective forstrains notproducing ~-Iactamase; -. noteffective. 'Based on available datafrom clinical trials and laboratory studies. tPercentage of cases of acute sinusitis caused by this pathogen.
fective therapy. Because this disease may have been so widely overlooked and misunderstood. it is important for physicians to base treatment on a rational medical approach. One way to assure effective therapy for patients with sinusitis is to think about the effect that a potential therapy may have on the ostiomeatal complex. Will the therapy control infection and/or relieve obstruction? Any effective approach should encompass these goals. Management goals for treatment of sinusitis include the following: I. Control of infection 2. Reduction of tissue edema 3. Facilitation of drainage 4. Maintenance of patency of the sinus ostia
Antlblotlo Therapy The primary goal of antibiotic therapy is to control infection in the closed sinus cavities, but the other therapeutic goals for sinusitis management should also be kept in mind. Reduction of tissue edema. normalization of gas exchange. and sinus drainage are necessary for restoration of normal physiologic function of the si-
nuses. Maintenance of ostial patency is also essential for clearing infection and preventing chronicity and recurrent acute attacks. The unreliability of cultures of secretions obtained by nasal swab dictates empiric antibiotic therapy directed at the most common pathogens. Antral puncture with aspiration is not usually indicated before the patient is initially treated with antibiotics. In fact. otolaryngologists generally prefer that patients be receiving antibiotic therapy before antral puncture is performed. Antibiotic protocol. Drs. Winther and Gwaltney will present the bacteriology of acute sinus infection and antibiotic selection in depth. From the clinician's viewpoint. however. it is essential to have a predetermined rationale for choice of appropriate antimicrobial agents. The first-line drugs of choice for treatment of acute sinusitis are ampicillin (500 mg every 6 hours for 14 days), or amoxicillin (500 mg every 8 hours for 14 days), Either should be effective against all likely bacteria except Staphylococcus aureus, ~-lactamase producing Haemophilus injluenzae and Moraxella catarrhalis, some anaerobes, and many gram-negative
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Table 2. Sinusitis therapy: Selection based on therapeutic goals
-
AcftOlll
Antibiotics Decongestants
Topical steroids Mucoevacuants
Amoxicillin/trimethoprimsulfamethoxazole Phenylpropanolamine (PPA) Phenylephrine Oxymetazoline Beclomethasone dipropionate Flunisolide Guaifenesin Potassium iodide
Treats infection Increases ostial diameter Facilitates drainage Reduces inflammation Reduces mucous secretion Thins secretions Aids drainage
NOTE, The role of antihistamines has not been established in the treatment of acute sinusitis.
aerobic bacilli. A 2-week course of effective antibiotic therapy is considered adequate for acute sinusitis, but 3 or 4 weeks-or longer-may be necessary for adequate control of chronic sinus infection. For patients who are allergic to penicillin, trimethoprim (160 mg)/sulfamethoxazole (800 mg, one tablet twice daily) (TMP/SMX), is the alternative drug of choice,6 especially in areas with a high incidence of ~-lactamase-producing H. influenzae, which, along with pneumococci, are no longer uniformly sensitive to tetracycline. When patients fail to respond to ampicillin or amoxicillin alone, the combination of amoxicillin and clavulanate potassium (500 mg, one tablet every 8 hours) is likely to be effective. This combination is effective against S. aureus and ~-lactamase-producing strains of H. influenzae and M. catarrhalis, In children, the combination of erythromycin and SUlfisoxazole is often considered the treatment of choice, For patients ill enough to require hospitalization, a second-generation cephalosporin such as cefuroximeshouldbe given. Other cephalosporins may provide inadequate sinus fluid levels to be effectiveagainst many common pathogens." The recommended doses for adults and children, as well as the reported clinical efficacy of the antibiotics mentioned in this section, are summarized in Table I. Aaeulng real coat•. Cost effectiveness must always be a consideration, and the cost of recommended antibiotics varies greatly. For example, in our hospital the wholesale drug cost of 10 days of therapy with amoxicilJin, ampicillin, or TMP/SMX is less than $6, compared with about $21 for amoxicillin-clavulanate, about $27.50 for cefaclor, and $32 for erythromycin. Physicians,patients, andthird-party payersalike should understand, however, that even a $100 basic drug cost for an extended course of an effective antibiotic, along
with an appropriate decongestant, could save many times that amount in future examinations and treatment of chronic sinusitis-not to mention the savings in pain and inconvenience to our patients. Decongestant Therap.y l
There are several goals of decongestant therapy. They include the reduction of tissue edema, facilitation of drainage, and maintenance of the patency of the sinus ostia. In short, decongestants are necessary to meet the management goals for acute sinusitis. ' Basically, decongestants are available in two forms: topicaland systemicfor oral administration. Each agent differs slightly in its mechanisms of action (Table 2). Topical agent.. Locally active vasoconstrictor agents provide almost immediatesymptomatic relief by shrinkingthe inflamed and swollen nasal mucosa, Phenylephrine HCl nasal spray 0.5% and oxymetazoline HCI nasal spray 0.05% are topical decongestants frequently used in treatment of acute sinusitis in adults. Phenylephrine spray should be self-administered with the head in the upright position three or four times daily for 3 days, and no longer than a week. Oxymetazoline nasal spray should also be administered with the head erect, two or three sprays in each nostril two or three times daily, for no longer than 3 to 4 days. Use of either agent for longer than recommended periods or with more frequent applications entails a high risk of rebound vasodilatation. Oral systemic agent.. When decongestion is necessary for longer than 3 days, an oral syS#Cmic agent such as phenylpropanolamine (PPA) or pseudoephedrine is preferred. Oral decongestants are aadrenergic agonists that reduce nasal blood flow. Theoretically, these oral systemic agents have the potential to act on tissuesdeep in the ostiomeatalcomplex, where topical agents may not penetrate effectively. Roth
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OtolaryngologVHead and Neck Surgery
.74 STAFFORD
et al. 8 have demonstrated that systemic decongestants, CONCLUSION like topical agents, improve nasal airway patency. The Early diagnosis and early, aggressive antibiotic therefficacy of topical preparations may diminish after sevapy may reduce patient suffering and save a sizable eral days of treatment. This does not occur with the proportion of health care dollars spent on treatment of oral systemic formulations. Melen et al. 9 demonstrated sinusitis. From hospital medical records, orders for rathat PPA increases the functional diameter of the rnax-x-- diography, and pharmacists' records of prescriptions iIIary ostium. Oral decongestants are also available in filled, we believe that early diagnosis and early effective combination with mucoevacuants, such as guaifenesin, therapy are the exceptions rather than the rule. Only that may help to thin secretions and facilitate drainage. with an increased index of suspicion of the probability PPA and pseudoephedrine are generally considered of acute sinusitis can we effectively reverse these equally safe and effective as oral decongestants. In the trends. past, some clinicians had expressed concern about PPA producing or potentiating hypertension or other central REFERENCES nervous system stimulant responses. However, a num1. Gwaltney J Jr. Diagnostic and medical management of acute sinusitis. Presentation at The American Academy of Allergy and ber of controlled clinical studies have supported the Immunology. San Antonio. Texas, Feb. 5, 1989. overall' safety of PPA when taken at appropriate doses 2. Kern EB. Sinusitis. J Allergy Clin Immunol 1984;73:25-31. in approved dosage form.!":!' Additionally, concerns 3. MacKay ON. Antibiotic treatment of rhinitis and sinusitis. Am over the possibility that PPA might raise blood pressures J Rhinol 1987;1:83-5. significantly were addressed recently by Kroenke 4. Rachelefsky GS. Katz RM. Siegel SC. Chronic sinusitis in children with respiratory allergy: the role of antimicrobials. J Allergy et a1. , 14 who concluded that PPA affects blood pressure Clin Immunol 1982;69:382-7. no more than does placebo, in patients with stable hyS. Gill FF. Neiburger JB. The role of nasal cytology in the diagnosis pertension. of chronic sinusitis. Am J Rhinology 1989;3:13-5. Antihistamines have not proved to be effective in the 6. Hamory BH. Sande MA, Sydnor A Jr, Seale DL, Gwaltney JM management of acute sinusitis and are not usually inJr. Etiology and antimicrobial therapy of acute maxillary sinusitis. J Infect Dis 1979;139:197-202. dicated as symptomatic or adjunctive therapy. Because 7. Malow JB, Creticos CM. Nonsurgical treatment of sinusitis. of their anticholinergic action, classic antihistamines Otolaryngol Clin North Am 1989;22:809-18. can cause dryness of mucous membranes and may in8. Roth RP, Cantekin VI. Bluestone CD. Nasal decongestant acterfere with the clearance of purulent mucous secretivity of pseudoephedrine. Ann Otol Rhinol Laryngol 1987; tions. Even the newer, nonsedating antihistamines that 86:235-41. 9. Melen 1. Friberg B. Andreasson L, et al. Effects of phenylprohave no significant anticholinergic effects have no role panolamine on ostial and nasal patency in patients treated for in the treatment of most patients with acute sinusitis. chronic maxillary sinusitis. Acta Otolaryngol 1986;10I:494-500. The appropriate role of antihistamines is for treatment 10. Goodman RP, Wright JT, Barlascini CO. et al. The effect of of allergic manifestations. Antihistamines are indicated phenylpropanolamine on ambulatory blood pressure. Clin Pharonly when patients manifest profuse, thin, watery rhimacol Ther 1986;40:144-7. II. Liebson 1, Bigelow G, Griffiths RR, Funderburk FP. Phenylnorrhea, sneezing, and pruritus.
Indloatlons tor Follow-up If antibiotic therapy initiated on the day of diagnosis for acute sinusitis has not provided adequate relief of symptoms after 7 days, a 10- to 14-day course of therapy should be prescribed with another antibiotic with a broader spectrum of sensitivity." If symptoms persist after 21 days of antibiotic therapy, referral for more definitive studies is probably indicated. Failure of appropriate antibiotic therapy suggests that the patient's sinusitis has extended beyond the acute stage. Failure of ampicillin or amoxicillin, followed by failure of the amoxicillin-clavulanate combination, suggests the possibility of an unusual pathogen or an anatomic abnormality. Endoscopic nasal surgery may be necessary to reopen and maintain the patency of the sinus ostia and ostiomeatal channels to allow healing.
12.
13.
14.
15.
propanolamine: effects on subjective and cardiovascular variables at recommended over-the-counter dose levels. J Clin Pharmacol 1987;27:685-93. Silverman HI. Kreger BE, Lewis GP. Lack of side effects from orally administered phenylpropanolamine and phenylpropanolamine with caffeine: II controlled three phase study. Curr Ther Res 1980;28:185-94. Blackburn GL, Morgan JP, Lavin PT, Noble R, Funderburk FR, lstfan N. Determinants of the pressor effect of phenylpropanolamine in healthy subjects. JAMA 1989;261:3267-72. Kroenke K. Omori OM, Simmons 10, Wood DR, Meier NJ. The safely of phenylpropanolamine in patients with stable hypertension. Ann Intern Med 1989;111:1043-4. Reilly J5, Kenna MA. Managing the spectrum of childhood sinusitis. J Respir Dis 1987;8:75-85.
DISCUSSION Dr. Kennedy: In regard to your citation of Dr. Kern' s classification of sinus disease, I believe his position was
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Clinician's view of sinusitis .71
that mucosal disease in chronic sinusitis becomes irreversible after 3 months. That does not seem to be the case; with good ventilation and drainage, mucosal damage may reverse over time. Dr. Stafford: We now have better methods of visualizing the mucosa than Dr. Kern had. Dr. Kennedy: Exactly. And I support your defense of transillumination as a useful diagnostic tool. Transillumination provides similar information to ultrasonography. Ultrasonography is difficult to do and has highly variable results, and provides no information about the ethmoid sinus. Although failure of a sinus to transilluminate does not confirm sinusitis, it still provides useful information; opacity could occur because of a small hypoplastic sinus. If a sinus does illuminate, symptoms could be the result of a cyst within the sinus or minor mucosal thickening. This is useful information.
Now, with regard to the use of topical or systemic corticosteroids as second-line therapy, will you discuss your approach to both acute and chronic sinusitis? Dr. Stafford: When a patient with acute sinusitis has a closed-off cavity, we prefer to use topical vasoconstrictor drugs long enough to open the ostia. We feel that antiinflammatory topical corticosteroids then help maintain patency. Dr. Druce: Though many physicians are concerned that corticosteroids might exacerbate sinus infection, this does not seem to be the case when antibiotics are being administered. However, I know of no reason to use systemic corticosteroids in therapy for acute or chronic sinusitis, unless the patient also has a systemic condition that warrants their use.
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