Sinus Infection (Sinusitis)

short red hair woman blowing her noseSinusitis ruins otherwise comfortable lives of many individuals. It is an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air, but when germs (bacteria, viruses, and fungi) enter your body and your sinuses fill up with them and fluid, it can grow and cause an infection. Common cold, allergic rhinitis (swelling of the lining of the nose), nasal polyps (small growths in the lining of the nose), or a deviated septum (a shift in the nasal cavity) are all possible causes of sinus blockage.

There are different types of sinusitis, including:

Acute sinusitis: A sudden onset of cold-like symptoms such as runny, stuffy nose and facial pain that does not go away after 10 to 14 days. Acute sinusitis typically lasts 4 weeks or less.

Subacute sinusitis: An inflammation lasting 4 to 8 weeks.

Chronic sinusitis: A condition characterized by sinus inflammation symptoms lasting 8 weeks or longer.

Recurrent sinusitis: Several attacks within a year.

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Signs and Symptoms of Acute Sinusitis

Facial pain/pressure
Nasal stuffiness
Nasal discharge
Loss of smell
Cough/congestion
Fever
Bad breath
Fatigue
Dental pain

Signs and Symptoms of Chronic Sinusitis
People with chronic sinusitis may have the following symptoms for 8 weeks or more:Facial congestion/fullness
A nasal obstruction/blockage
Pus in the nasal cavity
Fever
Nasal discharge/discolored postnasal drainage
Headaches
Bad breath
Fatigue
Dental pain

Dr.Paul Kattupalli’s treatment approach to sinusitis:

Acute viral rhinosinusitis (AVRS) is expected to improve or resolve within 10 days. Patients with AVRS will be managed with supportive care. Patients who fail to improve after ≥10 days of symptomatic management are more likely to have acute bacterial rhinosinusitis (ABRS) and will be managed as ABRS.

Symptomatic management of acute rhinosinusitis (ARS) aims to relieve symptoms of nasal obstruction and rhinorrhea. Dr.Paul suggests over-the-counter (OTC) analgesics and saline nasal irrigation. He also suggests treatment with intranasal glucocorticoids . Decongestants may be useful when eustachian tube dysfunction is a factor for patients with AVRS but are not likely to be helpful for patients with ABRS and have adverse side effects.

Urgent, early referral is essential for patients with symptoms that are concerning for complicated ABRS or have evidence of complications on imaging.

ABRS may also be a self-limited disease. Systematic reviews and meta-analyses have found that 70 to 80 percent of immunocompetent patients improve within two weeks without antibiotic therapy. Dr.Paul suggests symptomatic management and observation over a seven-day period (watchful waiting) for immunocompetent patients with ABRS who have good follow-up. He starts antibiotic therapy after diagnosis for patients who do not have good follow-up.

Antibiotics should be started in patients who have been managed with observation who have worsening symptoms or fail to improve within the seven-day observation period.

There are also a variety of reasons for patients to have a suppressed immune system, and treatment decisions for immunocompromised patients should be made on a case-by-case basis. They may warrant immediate antibiotic treatment and/or specialist referral. Treatment decisions for patients with other comorbidities that can affect immune function (eg, diabetes) should also be individualized.

In light of increasing microbial resistance to antibiotics, Dr.Paul suggests initial empiric treatment with either amoxicillin or amoxicillin-clavulanate rather than macrolides (clarithromycin or azithromycin) or trimethoprim-sulfamethoxazole.

For patients without risk factors for resistance, He treats with either  amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) or amoxicillin-clavulanate 500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily).

Patients with risk factors for pneumococcal resistance  should be treated with high-dose amoxicillin-clavulanate (2 g/125 mg extended-release tablets orally twice daily).

•Doxycycline (100 mg orally twice daily or 200 mg orally daily) is a reasonable alternative for initial therapy in patients with penicillin allergy. For penicillin-allergic patients who can use cephalosporins, using an oral third-generation cephalosporin (eg, cefixime 400 mg daily or cefpodoxime 200 mg daily) with or without oral clindamycin (150 mg or 300 mg every six hours) is another option. A respiratory fluoroquinolone (levofloxacin 500 or 750 mg orally or moxifloxacin 400 mg orally once daily) is another alternative for penicillin-allergic patients. However, fluoroquinolones should be reserved for those who have no alternative treatment options as the serious adverse effects associated with fluoroquinolones generally outweigh the benefits for patients with acute sinusitis.

Patients who are improving on initial therapy should be treated for a course of five to seven days.

Patients with ABRS are expected to show some response to empiric antimicrobial therapy within seven days. Patients who fail initial therapy should have the diagnosis of ABRS confirmed . While imaging is not indicated for uncomplicated ABRS, imaging is reasonable in patients who fail initial therapy and whose symptoms are not completely consistent with ABRS to rule out sinusitis and/or evaluate for alternative diagnosis.

An alternative treatment strategy is indicated for patients with confirmed uncomplicated ABRS whose symptoms worsen or fail to show some improvement in that time frame. Choice of therapy will depend on initial antibiotic therapy. Treatment options include high-dose amoxicillin-clavulanate  (2 g/125 mg extended-release tablets orally twice daily) or a respiratory fluoroquinolone (levofloxacin 500 mg orally once daily or moxifloxacin 400 mg orally once daily).

For penicillin-allergic patients, doxycycline 100 mg orally twice daily or 200 mg orally daily, levofloxacin 750 mg or 500 mg orally once daily, or moxifloxacin  400 mg orally once daily are appropriate alternatives.

Patients who fail ≥2 courses of appropriate antibiotics should have imaging and be referred for further evaluation.

Recurrence of symptoms within two weeks of response to initial treatment usually represents inadequate eradication of infection.

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