Acute

Cards (21)

  • Demographics:
    • Common
    • Higher incidence in women
    • Most common in 5th-7th decade
    • Although can affect all ages and both sexes
  • Risk factors:
    • Inflammation - URTI, smoking, chlorine, asthma, dental infection, allergic rhinitis
    • Pressure changes causing irritation - diving, air travel
    • Anatomical - older age resulting in weaker cartilage and less supported nasal passage, deviated septum, polyps, tumour
    • Impaired ciliary function - cystic fibrosis and primary ciliary dyskinesia, smoking
    • Immunodeficiency
  • Most common causes:
    • Most common = viral URTI
    • Common viral pathogens = rhinovirus, parainfluenza, influenza
    • Bacterial infection can occur when drainage of the sinus if affected, leading to blockage and build-up of bacteria - bacterial infection secondary to viral infection
  • Pathophysiology:
    • Virus affects nasal mucosa first and causes symptoms - nose blowing prompts propagation of infection to paranasal sinuses
    • As infection develops it leads to excess sinonasal secretions, increased vascular permeability and mucosal oedema
    • The inflammation of sinonasal mucosa obstructs sinus ostia (bony opening in sinus), leading to mucus retention, decreased mucociliary clearance, increased pressure causing pain
    • This predisposes to secondary bacterial infection
  • Typical symptoms:
    • Nasal congestion
    • Nasal discharge - purulent
    • Facial pressure/pain/headache - worse on bending forward
    • Anosmia
    • Ear pain - often due to eustachian tube dysfunction due to obstruction
    • Fever
    • Halitosis - purulent mucus drips down back of throat
    • Dental pain
    • Fatigue
  • Examination findings:
    • Facial tenderness to gentle palpation
    • Post-nasal pharyngeal secretions or exudate
    • Pain on percussion or palpation over upper teeth
    • Middle ear effusion
    • Nasal signs - inflammation, oedema, mucopurulent discharge
    • Associated pathology - nasal polyps, anatomical abnormalities e.g. septal deviation
  • Classification:
    • Acute = symptoms resolved within 12 weeks, further split into:
    • Acute viral (common cold) - symptoms less than 10 days
    • Post-viral acute - symptoms worsen after 5 days, or persist for more than 10 days (less than 12 weeks)
    • Acute bacterial
  • Uncomplicated sinusitis:
    • Inflammation doesn't extend beyond anatomical boundaries of nasal cavities and paranasal sinuses
  • Complicated sinusitis:
    • Rare
    • Extension of infection beyond nasal cavities and paranasal sinuses
    • The extension can lead to significant complications that require urgent hospital admission and treatment
    • Periorbital and orbital cellulitis
    • Subperiosteal abscess
    • Osteomyelitis
    • Intracranial abscess
    • Meningitis
    • Cavernous sinus thrombosis
    • Cranial nerve palsy (rare)
  • Diagnosis:
    • Clinical based on signs and symptoms
  • Diagnose acute sinusitis if there is sinonasal inflammation lasting less than 12 weeks associated with sudden onset of at least 2 diagnostic symptoms:
    • Nasal blockage/obstruction/congestion or nasal discharge
    • Facial pain/pressure (or headache)
    • Anosmia
  • Other features suggestive of acute sinusitis:
    • Upper airway symptoms - sore throat, hoarseness, cough
    • Non specific symptoms - malaise, fatigue, fever
  • Suspect acute bacterial sinusitis if at least 3 of the following are present:
    • Symptoms more than 10 days
    • Discoloured or purulent nasal discharge
    • Severe localised pain (often unilateral, particularly pain over teeth and jaw)
    • Fever above 38
    • Marked deterioration after an initial milder phase - double sickening
  • Red flags that suggest complicated sinusitis:
    • Periorbital oedema
    • Proptosis
    • Visual changes
    • Abnormal extra-ocular eye movements
    • Pain on eye movements
    • Severe persistent headache
    • Cranial nerve palsies
    • Altered mental status
    • Meningism
  • Investigations:
    • Only required if suspect complicated infection
    • Cultures - nasal, blood
    • Bloods - FBC, U&Es, LFTs, bone, CRP
    • Imaging - facial and head e.g. CT or MRI
  • Acute viral sinusitis management (symptoms less than 10 days)
    • Do not offer antibiotics
    • Reassure that should self-resolve
    • Analgesia/antipyretics
    • Trial of nasal saline or nasal decongestants
    • Clean nose with saltwater solution
    • Safety net to get review if symptoms worsen or don't improve after 3 weeks
  • Post-viral acute or suspected acute bacterial sinusitis management:
    • Same conservative management as with acute viral
    • Consider short term high-dose nasal corticosteroids (mometasone) for 14 days
    • Consider giving a delayed antibiotic prescription to use if symptoms don't improve within a further 7 days or symptoms are worsening
    • Evidence that antibiotics make little difference to how long symptoms last
  • Antibiotic options:
    • 1st line = phenoxymethylpenicillin
    • Co-amoxiclav if systemically unwell
    • If penicillin allergy - doxycycline or clarithromycin
  • Admit patients to hospital if:
    • Severe systemic infection and/or signs of sepsis
    • Intraorbital/periorbital complications - oedema, cellulits, proptosis, double vision, ophthalmoplegia, new reduced visual acuity
    • Intracranial complications - concerned about meningitis, focal neurological signs, cranial nerve palsies, severe persistent headache, reduced consciousness
  • Urgent outpatient referral:
    • Concerned is due to cancer in the nose causing blockage:
    • Persistent unilateral symptoms such as:
    • Nasal obstruction
    • Nasal discharge
    • Nosebleeds
    • Crusting
    • Facial swelling
  • Cases that need referral (urgency depends on judgment):
    • Recurrent episodes
    • Anatomic defect causing obstruction
    • Comorbidity complicating management e.g. nasal polyp
    • Doubt about diagnosis
    • No improvement after 10 days of antibiotic treatment/resistant organisms
    • immunocompromised patients