Acute Rhinosinusitis

Diagnosis
The diagnosis of rhinosinusitis is made by looking at the specific combinations of
symptoms based on patient history, with the sole physical finding that may be included being
nasal purulence, either viewed by anterior rhinoscopy or as a postnasal discharge on
pharyngeal examination. The emphasis on obtaining a patient history and performing a
limited physical examination is based on the fact that most patients can be effectively treated
without the necessity of nasal endoscopy, radiographic studies or bacterial cultures.
A strong history consistent with rhinosinusitis would require the presence of either two
major factors, or one major and two minor factors. When only one major factor or two or more
minor factors were present, this constituted a suggestive history in which rhinosinusitis should
be included in the differential diagnosis.

Differential Diagnosis

Allergic rhinitis and non-allergic

rhinitis
Viral upper respiratory tract infection
Nasal polyps
Sinonasal tumors

Nasopharyngeal tumor, granulomata,

dental infections
Enlarged or infected adenoids in
children

 Management
A. Acute Bacterial Rhinosinusitis (ABRS)
The treatment for ABRS includes causative treatment using antibiotics and
adjunctive treatments to relieve the symptoms. The regimen of antibiotics given differ
according to the signs and symptoms shown in patients.
Antibiotic
1) Uncomplicated ABRS with mild pain and fever <38.3C
- Delay antibiotic treatment for up to 7 days, because the illness will usually have
subsided by then even without antibiotic medication.
- If the illness persists or worsens before 7 days time, antibiotics are initiated
2) ABRS with moderate to severe pain or temperature >38.3C
- Should be started on antibiotics right away.
- The first line antibiotics used are amoxicillin.
- The duration of treatment depends, but is usually between 5 to 10 days.
3) With Penicillin Allergy
- The alternatives are trimethoprim-sulfamethoxazole or a macrolide (azithromycin,
erythromycin).
4) Recently Treated With Antibiotic (in the past 4-6 weeks)
- Suspected infection with resistant bacterium.
- The recommended medication is fluoroquinolone or high-dose amoxicillinclavulanate.
5) Children Suspected of S. pneumoniae Infection
- They require a high-dose amoxicillin regimen.
Analgesic/Antipyretic
- Analgesic and antipyretic is often necessary to alleviate pain and fever so the
patient may have adequate rest and resume normal activities.
- The recommended medication is acetaminophen.
Decongestant
- Decongestant is recommended to reduce mucosal edema and facilitate aeration
and drainage in the nasal cavity.
- May be topical or systemic, although topical is showed to have a greater efficacy
than systemic ones.
- Topical decongestant should not be used longer than 3 days because of the risk of
developing rhinitis medicamentosa
- The recommended medication is oxymetazoline (topical decongestant) or
pseudoephedrine (systemic decongestant)
Nasal Saline Irrigations
- Nasal irrigation may be used to soften viscous secretion and improve mucociliary
clearance.
- Buffered hypertonic saline irrigations have shown more benefit compared with
isotonic saline.
Corticosteroid
- Intranasal corticosteroids reduce inflammation and edema of the nasal mucosa,
nasal turbinates, and sinus ostia.
- Topical corticosteroid may improve symptoms but there is no evidence supporting
systemic corticosteroid.
- The recommended medication is fluticasone propionate (topical).
Antihistamine
- Only when the patients has symptoms that suggest an allergic component to their
disease process.
- Loratadine is the recommended drug.

Mucolytic
- There is no evidence supporting mucolytic use in ABRS and thus is not
recommended.
- Although, in theory mucolytics thins mucus and improves nasal drainage. The
medication usually used is guaifenesin.
Other Adjunctive Therapies
- Hydration is recommended in patients as another method to relieve nasal
congestion.
Treatment Failure
Treatment failure is described as a worsening (progression of signs and
symptoms or onset of new ones) and failure to improve (lack of reduction in signs or
symptoms) in 7 days.
1) Patients Initially Managed With Observation (delayed antibiotics)
- Begin treatment with amoxicillin or appropriate alternative in patients with
penicillin allergy.
2) Treated With Antibiotics
- Likely to be infected with bacteria with reduced susceptibility such as H.
influenzae, M. catarrhalis, and S. penumoniae.
- The recommended treatment would be high-dose amoxicillin-clavulanate or a
respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin).

B. Acute Viral Rhinosinusitis (AVRS)

- The management of AVRS is focused on symptom control, as it is a self-limited
condition and there is no evidence supporting benefit of antibiotic prophylaxis in
preventing conversion to ABRS. The therapy for symptom control is the same as with
ABRS, which consists of analgesic/antipyretic, nasal irrigation, decongestants, and
mucolytics. Corticosteroids, both topical and systemic, shows no evidence of benefit in
treatments of AVRS. It is the same with antihistamine except in cases where allergy is
suspected to play a part in the disease process.
C. Acute Fulminant Invasive Fungal Sinusitis
- The management of this type of sinusitis necessitates combined medical and
surgical therapies. The medical therapy consists of systemic antifungal therapy with
amphotericin or voriconazole, but this alone is insufficient. Early aggressive endoscopic
sinonasal debridement of all involved tissue is necessary for any patients with biopsyproven disease or in whom there is high clinical suspicion. The goal of debridement
include reduction of the fungal load, slowing progression of disease, and obtaining
specimen. Adjunctive measures to tackle this disease involve correcting the underlying
immune deficit, such as correction of diabetic ketoacidosis, transfusion of WBC, or
administration of granulocyte colony-stimulating factor.
Complication
Acute rhinosinusitis has three possible clinical courses: resolution,
development of sequelae, or development of chronic rhinosinusitis. Adverse sequelae of
acute rhinosinusitis can be broadly classified as extracranial, which includes local
complications, extension into the soft tissues, or extension into the orbit, and
intracranial involvement.
-

- Extracranial
Anosmia

Potts puffy tumor

Osteomyelitis
Sinus
cavernosus

- Intracranial
Sinus
cavernosus
thrombosis
Epidural abscess
Intracranial abscess
Meningitis

thrombosis (due to orbital

involvement)
Preseptal cellulitis
Orbital abscess

Orbital cellulitis
Subperiosteal abscess

Subdural abscess
Superior
sagittal
thrombosis

sinus