BAB 33

RHINOSINUSITIS AKUT

ABSTRAK

This chapter provides an in-depth discussion of acute rhinosinusitis, beginning with definitions of
rhinosinusitis and its epidemiology and economic impact. The pathophysiology of acute viral
rhinosinusitis and acute bacterial rhinosinusitis are reviewed. Next, a discussion of appropriate
components of patient history and physical examination, as well as indications for radiologic imaging in
the setting of acute rhinosinusitis, is undertaken. Finally, acute rhinosinusitis treatment modalities and
complications are highlighted.

Sinusitis is defined as inflammation of the paranasal sinuses, and rhinitis as inflammation within the
nasal cavity. In 1996, the Task Force on Rhinosinusitis, sponsored by the American Academy of
Otolaryngology-Head and Neck Surgery, the American Rhinologic Society, and the American Academy of
Otolaryngologic Allergy recommended the replacement of the term sinusitis with rhinosinusitis. This
recommendation was based on rhinitis commonly preceding sinusitis, as well as the fact that sinusitis
without rhinitis is extremely rare (1).

There are multiple potential contributors to the development of rhinosinusitis, including both host and
environmental factors (Table 33.1). Examples of host characteristics that may contribute to
rhinosinusitis include congenital conditions, such as cystic fibrosis or immotile cilia syndrome, allergic
states or altered immune function, anatomic abnormalities, systemic diseases, and neural mechanisms.
Some external factors that can result in rhinosinusitis are infectious agents, trauma, exposure to noxious
chemicals or medications, and surgical changes.

In a given patient with rhinosinusitis, many host and environmental factors may be present
simultaneously. For example, a patient with cystic fibrosis who has altered anatomy from prior surgery
may present with an acute bacterial infection of the sinonasal cavities. Therefore, defining rhinosinusitis
based on etiology could become very complicated. For this reason, the Task Force on Rhinosinusitis
elected to classify this disorder based on temporal factors (1) (Table 33.2). Acute rhinosinusitis is defined
by the presence of the condition for up to 4 weeks (1). Chronic rhinosinusitis can be diagnosed after the
condition has been present for at least 3 months (1). The term subacute rhinosinusitis is used when the
duration is between 4 and 12 weeks (2). When there are four or more episodes of acute bacterial
rhinosinusitis (ABRS) in 1 year with resolution of symptoms in between episodes, the diagnosis is
recurrent acute rhinosinusitis (2).

The Task Force on Rhinosinusitis examined the definition, diagnosis, management, and outcome
analysis of rhinosinusitis in order to facilitate patient care and research (1,3). These efforts have been
furthered by additional panels in 2004 (sponsored by the American Academy of Otolaryngology-Head
and Neck Surgery, the American Rhinologic Society, the American Academy of Otolaryngologic Allergy,
the American Academy of Allergy, Asthma, and Immunology, and the College of Allergy, Asthma, and
Immunology) and in 2007 (sponsored by the Academy of Otolaryngology-Head and Neck Surgery
Foundation) (2-4). The goal of this chapter is to utilize these resources in addition to current literature to
review acute rhinosinusitis, including its epidemiology, pathophysiology, clinical presentation, the role of
imaging, cur- rent treatment recommendations, and complications.
EPIDEMIOLOGY

Rhinosinusitis is a significant health care problem, believed to be increasing in both incidence and
prevalence (1). According to the 2009 Summary Health Statistics for U.S. Adults National Health
Interview Survey, over 29.3 million adults in the United States had been diagnosed with rhinosinusitis by
a physician (5). This comprises approximately 12.6% of the United States population. It has been
previously reported that the prevalence of rhinosinusitis is almost twice as common in women (20.9%)
as in men (11.6%) (5, 6). Other demographic factors, such as geography and race, may play a role as
well. The frequency of rhinosinusitis is generally lower in the Western United States (12.1%), as
compared to Southern regions (19.5%) (5). Non-Hispanic white persons (17.5%) and non-Hispanic black
persons (15.7%) have approximately twice the prevalence of rhinosinusitis as Hispanics (8.6%) (5,6).
While prior survey data have not demonstrated that poverty status is relevant to the frequency of
rhinosinusitis, regional variation in the frequency of rhinosinusitis may potentially be attributable to
differences in air quality, including presence of pollutants and allergens (5,6).

Economic Burden of Acute Rhinosinusitis

The economic impact of rhinosinusitis is staggering. Although references on this topic are few, thorough
investigations were published in 1999 and in 2004, based on the 1996 and 1998 National Health
Interview Surveys, respectively (6,7). The direct annual health care cost was estimated at $5.8 billion in
1996, of which about 30% was incurred to treat pediatric patients 12 years of age or younger (5,7).
Nearly 90% of the expenditures were associated with ambulatory or emergency department visits (5,7).
In 1996, there were 16.7 million outpatient physician, hospital office, and emergency department
encounters attributed to the primary treatment of sinusitis (7). The majority of out- patient office-based
physician care for sinusitis was delivered by primary care physicians (64.9% by family medicine and
internal medicine doctor, and 15.4% by pediatricians) (7). Overall, outpatient visits with sinusitis as the
primary diagnosis accounted for 36% of total medical expenditures in 1996, and medications to treat
this condition added another 17% (7). In 1992, Americans spent $200 million on prescription
medications and more than $2 billion on over-the-counter medications to treat sinusitis (8). The
Integrated Health Interview Series for 1997 to 2006 shows that 55.8% of patients with sinusitis spend
more than $500 annually on health care, higher than the amount spent by those suffering with chronic
diseases such as chronic bronchitis, hay fever, ulcer disease, and asthma (9).

The indirect costs of rhinosinusitis are, as one would expect, not insignificant and are also increasing.
The number of total restricted activity days due to rhinosinusitis rose from approximately 50 million per
year in the period between 1986 to 1988 to 61.2 million per year between 1997 and 2006 (5,9,10).
According to the 2007 estimates of workday productivity, this translates into $18.3 billion in lost
opportunity cost (9). Based on the 2006 survey data, patients with sinusitis miss an average of 5.67
work- days due to illness annually, as opposed to 3.74 missed workdays for those without sinusitis (9).
More difficult to quantitate, but certainly relevant within the realm of indirect costs, are the detrimental
effects of rhinosinusitis on quality of life and the impairment of daily functioning due to the significant
physical symptoms present when someone is suffering from rhinosinusitis (4).

PATHOPHYSIOLOGY AND MICROBIOLOGY

In order to fully understand the pathophysiology of rhino- sinusitis, one must consider the concepts of
inflammation and infection. Inflammation is a cascade of processes and signals via which mediators,
such as leukocytes, are enabled to eliminate foreign agents and repair damaged tissues (4,11). Acute
inflammation is characterized by exudation of fluid and plasma proteins from blood vessels with
emigration of leukocytes, predominantly neutrophils, as these cells gather to combat the offending
entity (4,11). It can be identified within minutes to hours of an insult or trigger. Chronic inflammation
develops as the condition persists over weeks to months. The hallmarks of chronic inflammation are the
presence of lymphocytes, macro- phages, eosinophils, and basophils, along with increased vascularity,
fibrosis, and tissue necrosis (4,11). Subacute inflammation is described as the interval period when
overlapping patterns of inflammation are observed (4). Infection is traditionally diagnosed when
microorganisms present in a host, directly interacting with the host tissue and replicating. This results in
expression of disease in the host organism (4). Bacterial infection is characterized by the presence of
one or more bacteria per high density field, which correlates to at least 1,000 colony forming units per
milliliter (4).

Histopathologically, acute rhinosinusitis is predominantly an exudative process (1,12). Examination of

tissue specimens reveals a mixed inflammatory cell infiltrate in which neutrophils predominate.
Hemorrhage, ulceration, and the presence of bacteria or fungi may also be seen (1,4,12).

Acute Viral Rhinosinusitis

The majority of acute rhinosinusitis is infectious in etiology (4) (Table 33.3). The leading pathogen is
viral. A sinus puncture study in patients with acute community-acquired rhinosinusitis demonstrated the
most common identifiable viral organisms in descending prevalence to be rhinovirus 15%, influenza virus
5%, parainfluenza virus 3%, and adenovirus 2% (4,13). The pathogenesis of infection by the most
common of these, the rhinovirus, was very well delineated in the end of the twentieth century by
Gwaltney’s group at the University of Virginia. The rhinovirus enters the body through the nose, either
by direct inoculation or by large airborne particles (4,14). Viral particles travel in the mucus stream to
the adenoid region where they attach to a specialized receptor (rhinovirus receptor intercellular
adhesion molecule 1) on lymphoepithelial cells overlying lymphoid follicles (4,15—17). An inflammatory
reaction is thus incited, and common acute viral rhinosinusitis (AVRS) symptoms, including sore throat,
nasal obstruction, and rhinorrhea develop within hours of exposure (4,18).

Although historically viruses were thought to cause predominantly rhinitis, involvement of the paranasal
sinuses in the clinical setting of AVRS is well documented radio- logically in both adults and children
(19,20). These studies were performed predominantly in the late 1980s and early 1990s at a time when
people were comparing the relatively new modalities of computed tomography (CT) and magnetic
resonance imaging (MRI) against the standard imaging modality for rhinosinusitis, plain film
radiography. Abnormalities, including air—fluid levels, aerosolized secretions, and thickened mucosa are
seen most often in the maxillary sinuses 87%, but also in the ethmoid sinuses 65%, the frontal sinuses
32%, and the sphenoid sinuses in 39% (4,21). These findings are associated with exocytosis of large
amounts of mucin by goblet cells in the paranasal sinus epithelium after they have been stimulated by
inflammatory mediators in the setting of acute viral infection (4).

Acute Bacterial Rhinosinusitis

ABRS classically occurs when a patient with AVRS develops a superimposed or secondary bacterial
infection (2). Only about 0.5% to 2.0% of AVRS are complicated by a bacterial infection (2,13). Yet, there
are still about 20 million cases of ABRS annually in the United States (2,22). AVRS can promote
development of ABRS by several mechanisms. The inflamed, edematous mucosa can obstruct sinus ostia
and impair mucus drainage (2,23,24). Mucociliary function and clearance is also directly affected by
inflammation; this deficit is magnified in a setting of increased mucus production (24). Infection by
bacterial pathogens that colonize the nose and nasopharyrix is promoted by mucus stasis and enabled
as the bacteria are deposited into the paranasal sinuses by nose-blowing (2,13,25).

This concept of the transition from AVRS to ABRS is critical as we discuss patient presentation and
accurate evaluation of progression of symptoms for diagnostic purposes. An episode of AVRS can be
complicated by a bacterial infection at any point, but early in the presentation the clinical distinction
between the two is essentially impossible. The more specific diagnostic criteria pertaining to the
timeline of the infection will be discussed later in this chapter, and are directly related to recommended
management of acute rhinosinusitis.

Microbiology of Acute Bacterial Rhinosinusitis

Knowledge regarding the microbiology of acute community-acquired bacterial rhinosinusitis in adults

has been predominantly delineated from cultures of maxillary sinus mucus, as these are the most
accessible of the paranasal sinuses (4). The majority of ABRS infections are due to a single bacterial
isolate, but about one-fourth of cases have polymicrobial infection, more commonly seen in pediatric
cases (4,26). The most common bacterial species isolated from the maxillary sinuses of patients with
uncomplicated ABRS are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
(2,27) (Table 33.3). The relative frequency of bacterial isolates in ABRS has proven to be a reproducible
relationship; 5. pneumoniae is identified in 20% to 43% of cases, H. influenzae in 22% to 35%, and M.
catarrhalis in 2% to 10% (2,26-31). The H. influenzae identified are predominantly the non-typeable
organisms (4). In the last several decades of the twentieth century there was a very large increase in the
prevalence of b-lactamase- producing H. influenzae to greater than 50%; however, in the 21st century
this appears to have stabilized at about 40% of the isolates (4,13,32,33). Macrolide-resistant S.
Pneumoniae is an increasing concern, and has been associated with increased risk of treatment failure
(34-36). Anaerobic bacteria account for only 2% to 6% of ABRS, some of which arise from primary dental
pathology (4).

Staphylococcus aureus and S. pyogenes play an interesting role in ABRS. Overall, they account for less
than 5% of cases, although S. aureus is often overestimated based on culture from nasal swabs, as
opposed to endoscopically-directed sinus cultures or direct sinus aspirates (4). Of note, S. aureus and S.
pyogenes have a higher propensity to cause complications of acute rhinosinusitis, such as intracranial or
orbital extension of the disease (4).

Special Scenarios—Microbiology of Nosocomial Acute Bacterial Rhinosinusitis

Nosocomial rhinosinusitis has a much higher prevalence of gram-negative organisms than community-
acquired ABRS. Examples of organisms found in nosocomial infections include Pseudomonas aeruginosa,
Klebsiella pneumoniae,
Enterobacter species, Proteus, and gram-positive cocci, such as streptococci and staphylococci (4). For
many years, we have known that patients at high risk for nosocomial rhinosinusitis are those who
require extended periods of intensive care with prolonged endotracheal intubation or nasogastric tubing
(4,37). Nasotracheal intubation has a higher risk for nosocomial sinusitis than orotracheal intubation
(4,38). Nosocomial sinusitis develops in 25% of patients requiring nasotracheal intubation for longer
than 5 days (4,39).

Special Scenarios—Acute Fulminant Invasive Fungal Sinusitis

Acute fulminant invasive fungal sinusitis is an aggressive disease characterized by the rapid spread of
fungi from the sinonasal mucosa into the orbit, soft tissues, and brain parenchyma via direct and
vascular invasion (40). Affected patients typically have a clinical condition associated with impaired
neutrophil function, such as hematologic malignancies, aplastic anemia, diabetes, acquired
immunodeficiency syndrome, organ transplant, or iatro- genic immunosuppression due to
chemotherapy (40). The most common etiologic organisms are Aspergillus and Mucormycosis species. In
this special patient population with decreased ability to mount an immune response to infectious
organisms, the signs and symptoms of disease may be subtle. The most common physical finding on
sinonasal endoscopy is an alteration in the mucosa of the nose and sinuses that suggest angioinvasion
by the fun- gal organisms, with ultimate hypoperfusion of tissues. White discoloration may suggest
tissue ischemia, whereas black discoloration is a late finding of tissue necrosis (40). Decreased mucosal
bleeding and sensation of anesthetic regions of the face or oral cavity may be signs of this invasive
process (40). The most common locations of mucosal abnormalities are middle or inferior turbinate,
nasal septum, and palate (41). The gold standard for diagnosis of this disease is permanent section with
Gomori methamine silver stain showing ”hyphal forms within the submucosa with or without
angiocentric invasion and tissue necrosis with minimal host inflammatory infiltrate“ (40) (Fig. 33.1A—C).
Because prompt diagnosis is imperative with this condition, frozen section with histopathologic
evaluation of any suspicious lesions is necessary to facilitate surgical resection and initiation of
antifungal therapy without delay. The potassium hydroxide—calcofluor white method is an alternative
rapid diagnostic technique in which potassium hydroxide is used to dissolve human material, and the
calcofluor white is used as an optic brightener that binds to the cell wall of the hyphae and fluoresces
when viewed with a fluorescent microscope (40)

Figure 33.1 Histopathology of invasive fungal sinusitis. A: Low power hematoxylin-eosin stain of an
invasive fungal sinusitis specimen. The white arrows indicate viable tissue surrounded by neurotic tissue.
B: High power hematoxylin—eosin stain of an invasive fungal sinusitis specimen. The black arrows
demonstrate fun- gal hyphae within a blood vessel. C: High power Gomori methenamine silver (GMS)
fungal stain highlighting invasive fungal hyphae within a blood vessel [black arrows). Photos courtesy of
Dr. Susan Muller.

CLINICAL PRESENTATION AND EVALUATION

Symptoms associated with rhinosinusitis are well recognized. The common symptoms include nasal
obstruction, nasal discharge, nasal purulence, postnasal drip, facial pressure and pain, alteration in the
sense of smell, cough, fever, halitosis, fatigue, dental pain, sore throat, aural fullness, otalgia, and
headache.

Patient History

When a patient presents with a constellation of symptoms consistent with acute rhinosinusitis, the care
provider should document all relevant symptoms. Clarification of the severity of symptoms and their
time course is critical in establishing an accurate diagnosis and forming an approriate treatment plan.
Assessment of the patient’s pain within this evaluation is strongly encouraged. Pain is one of the three
cardinal symptoms described as the diagnostic criteria for ABRS, and pain is a major reason why patients
seek medical care (4,42).

The early consensus report outlined by the Task Force on Rhinosinusitis in 1996 outlined a stratification
of major and minor symptoms in order to facilitate appropriate diagnosis of ABRS and help emphasize
its distinction from AVRS (1). Subsequent reports have replaced this model with a new concept,
highlighting three cardinal symptoms: purulent nasal discharge, nasal obstruction, and/or facial pain,
pressure, or fullness (2,42) (Table 33.4). The logic behind this new slant in symptom interpretation for
the diagnosis of ABRS is based upon the high sensitivity and relatively high specificity of these indicators
for ABRS, especially when they are present for 10 days or longer (2,42-44). Presence of purulent nasal
drainage, whether reported by the patient or seen on physical exam in the posterior pharyrix or
intranasally near the sinus ostia, correlates to the presence of bacteria on antral aspiration (2,45,46).
Findings of purulence also correlate with radio- graphic evidence of ABRS (2,47). Nasal obstruction is
associated with objective measures, such as rhinomanometry or nasal peak flow rate (2,48). Facial pain
and dental pain are also predictive of ABRS according to culture results and to radiographic findings, but
the location does not correlate with the specific sinuses involved (2,44,45,49).

After a thorough history of symptomatology is

obtained, a physician can often distinguish ABRS from AVRS or from acute rhinosinusitis due to
noninfectious etiologies (2). According to the 2007 guidelines, “ABRS is diagnosed when the three
cardinal symptoms are present for 10 days or longer beyond the onset of upper respiratory symptoms,
or when the symptoms or signs of acute rhinosinusitis worsen within 10 days after a period of initial
improvement (double-worsening)“(2). In the first 3 to 4 days of illness, AVRS cannot be distinguished
from an early transition to ABRS (2). Purulent discharge does not indicate the presence of bacteria
within the mucus, but rather it demonstrates the presence of neutrophils, which is characteristic of
acute inflammation regardless of the etiology. Clear rhinorrhea may be indicative of AVRS, allergic
rhinosinusitis, or other causes of nonallergic rhinosinusitis, such as vasomotor rhinitis. At 10 days or
more, inflammation and edema from AVRS may still be present; however, the condition should be
improving. If the symptoms are progressing at the 10 days timeframe, a diagnosis of ABRS is suggested
(2,42).

Fever is not included as a cardinal sign of ABRS because it only has a sensitivity and specificity of about
50% for this diagnosis (2,42-44). Patients with AVRS may have fever during the initial several days of
illness, which does not necessarily implicate an evolving secondary bacterial infection. However, if a
patient presents with the three cardinal symptoms, which seem to be particularly severe or with a high
fever within the first 3 to 4 days of onset of illness, a diagnosis of ABRS may be considered early (2,4,42).
Additionally, if there are symptoms suggesting progression beyond uncomplicated ABRS, despite the
duration of symptoms, treatment should be initiated early.

In addition to the thorough disease-specific history out- lined above, a care provider for a patient
presenting with symptoms of acute rhinosinusitis should perform a thorough medical and social history.
Presence of significant comorbid conditions, such as diabetes mellitus, immunocompromised status,
pulmonary disease, or congenital conditions are important to recognize when delineating a treatment
plan. A history of atopy or perennial allergic rhinitis is also relevant in treatment planning. Prior nasal or
facial trauma, facial surgery, or sinonasal surgery may affect a patient’s experience of symptoms and
disease course. A thorough review of a patient’s medications and medication allergies should be
obtained prior to applying any decongestant or local anesthetic to facilitate examination in the clinic,
and certainly prior to prescribing medications. Understanding the patient’s social history, including
tobacco exposure and conditions of their home and work environments is important for comprehensive
patient counseling. These factors may also suggest underlying conditions that are capable of
predisposing a patient to symptoms of rhinosinusitis and to the development of ABRS.

Physical Examination

Although a diagnosis of AVRS or ABRS can be accurately made with a patient history, a thorough physical
exam is imperative. Vital signs should be recorded. Examination of the head and neck should begin with
facial examination. Swelling, erythema, or edema localized over the involved cheek or periorbital edema
may suggest complicated ABRS with extension into the soft tissues. Palpation and percussion over the
face and maxillary dentition may assist in localizing pain. Examination of the eyes includes assessment of
the appearance of the conjunctiva, visual status testing, extraocular muscle function evaluation,
inspection for the presence of proptosis, and funduscopic or Tonopen exams if clinically indicated.
Otoscopic exam may reveal serous otitis media or acute otitis media. Anterior rhinoscopy is the basic
tool of the physical exam that most specifically relates to detecting pathology in the sinonasal passages
(4). Typically, the nose is evaluated before and after topical decongestion. Prior to application of
decongestant, such as oxymetazoline or neosynephrine, the anterior nasal passages and inferior
turbinates are inspected. After the nose has been decongested, one is usually able to visualize the
middle turbinate and inspect for pus in the region of the middle meatus as well as hyperemia, edema, or
crusting. Enlarged turbinates, presence of nasal polyps or masses, and nasal septal deviations may limit
the extent of this examination. Visualization of purulent postnasal drainage upon oropharyngeal
examination is rather sensitive and specific for ABRS (1). Vocal analysis may reveal a hyponasal quality,
consistent with reduced resonance due to decreased aeration of the paranasal sinuses (2). Auscultation
of the chest is especially important in any patients with history of pulmonary dysfunction given the
potential of lower airway inflammation coincidentally with upper airway infection. A full neurologic
evaluation including cranial nerve examination is indicated if there is any concern for complicated ABRS
with intracranial extension.

Endoscopic Evaluation

Endoscopically-directed middle meatus cultures are well correlated with cultures obtained by direct
maxillary sinus aspiration (2,50). Cultures of secretions from the nose or nasopharyrix, however, are
poorly representative of maxillary sinus cultures (2,50). Blind swabs of the nasal cavity are not
recommended since they are likely to be contaminated by normal colonizing bacteria (51). Directed
cultures are not necessary for the diagnosis or treatment of uncomplicated ABRS (2). Often the initial
evaluation of a patient with ABRS is by a primary care provider not trained in sinonasal endoscopic
techniques, which should not deleteriously affect delivery of appropriate care. The most important role
of endoscopy is the assessment and treatment of patients with refractory or chronic symptoms and in
patients who have impending or existing complications of rhinosinusitis (4). The indications for the
consultation of an otolaryngologist for endoscopy are symptomatic patients who fail to improve on
empiric therapy, patients with unilateral disease, patients with severe or disabling symptoms, patients in
whom complications are suspected, patients who have had recent sinonasal surgery, or
immunocompromised individuals (4) (Table 33.5). Sinonasal endoscopy can be performed with either a
flexible or a rigid scope. Flexible fiberoptic endoscopy is more comfortable for the patient and facilitates
access toward the sinuses in a non-operated patient. Rigid sinonasal endoscopy provides superior image
quality, allows one to obtain cultures and tissue samples if indicated, and provides the ability to control
epistaxis if encountered. Cultures can be obtained with a sterile swab or utilizing suction into a sterile
trap device.

IMAGING

Imaging modalities available to evaluate the nose and the paranasal sinuses are plain film radiography,
CT, and MRI (Table 33.6). Ultrasound has been used for evaluation of maxillary sinus disease, but its
sensitivity is poor (9,52). Ultrasound has limited capacity to accurately image the paranasal sinuses given
that they are surrounded by bone and contain air. It is very important to understand the strengths and
weaknesses of each of these imaging techniques in order to incorporate them into practice in a cost-
effective and algorithm-based manner. Information gained from a test should provide relevant data that
can be used to impact clinical decision making.

X-ray

Sinus plain film radiography series consist of three views: a lateral, Caldwell or posterior—anterior view
(central ray angle 15 degrees), and Waters or occipitomental view (orbitomeatal line angled 37 degrees
to horizontal plane) (2). Radiographs must be obtained with the patient in an upright position, as the
primary feature that is used to diagnose ABRS by plain film is the presence of air—fluid levels. Other
imaging findings consistent with a diagnosis of ABRS on plain film radiography are sinus opacification
and mucosal thickening (2). Relative advantages of plain films of the sinuses are low cost, low radiation
dosage (1.4 cGy per film), and possibility of a portable exam in an intensive care setting (53). A
prospective study using antral puncture results as the gold standard for diagnosis of ABRS showed that
complete opacification, air—fluid levels, or both on plain film radiography of the maxillary sinuses have
a diagnostic sensitivity of 73% and specificity of 80% (2,53—55). A similar study evaluating plain
radiography and using IT as the gold standard for diagnosis of acute maxillary sinus- itis reported the
sensitivity of radiography as 67% and specificity as 87% (53,55). The positive and negative predictive
values were reported as 82.5% and 76.9%, respectively (53,55). The sensitivity of plain film radiography
to diagnose ethmoid, frontal, and sphenoid sinusitis was worse at 0% to 58.9%, 1.9% to 54.0%, and 0%
to 38%, respectively (53,55). A negative plain film does not rule out the presence of sinusitis. By now
most agree that plain radiographs have limited value for acute rhinosinusitis (1,56).

Computed Tomography

IT is considered the gold standard for radiographic evaluation of the paranasal sinuses (1,2). Standard
sinus CT without contrast with 3-mm coronal cuts provides appropriate information regarding bony
anatomy, permitting understanding of the complex structure of the paranasal sinuses (53). Findings on if
that correlate with ABRS are ”opacification of the sinus cavities, air—fluid levels, and moderate to
severe mucosal thickening“ (2). The most accepted objective staging system used to evaluate the para-
nasal sinuses on IT is the Lund-Mackay classification system, which quantitates sinus disease by number
of sinuses with any degree of opacification in addition to evaluation for any anatomic variants (57).
Some of the limitations of if are increased cost and increased dose of radiation (5 to 6 cGy), which may
reach values up to 10 times the dose of a radiograph (2). Multidetector IT is a technology that facilitates
reduced total radiation in imaging of the sinuses because the patient is scanned in a single plane and the
remaining triplanar images are reconstructed from the original data set (2). Additionally, although
findings on CT may be consistent with a diagnosis of ABRS, they can- not accurately distinguish between
AVRS and ABRS (2,21). Further, there is a lack of correlation between localizing symptoms and findings
on if (2,49,58).

Using the presence of an air—fluid level or total opacification of a sinus as diagnostic criteria, sinus CT
has a 90% positive predictive value for diagnosis of ABRS when compared with culture of aspirated sinus
secretions (9,59). Still, the use of if in diagnosis of uncomplicated ABRS is not cost-effective and
universally not recommended (49,60-62). The role of if in acute sinusitis outlined in the literature is very
specific and consistent. if should only be performed when a com- plication of acute rhinosinusitis or an
alternative diagnosis is suspected (1,2,42). The complications of acute rhinosinusitis include orbital,
intracranial, or soft tissue involvement. Alternative diagnoses of facial pain may include neoplasm (2,42).
if may also be utilized when the patient has comorbidities or a clinical condition that predisposes him to
com- plications, such as diabetes, immunocompromised state, or a past history of facial trauma or
surgery (2). Iodine-contrast enhancement may help to identify extra-sinus extension of disease in clinical
situations when this is suspected (2).

Magnetic Resonance Imaging

Gadolinium-enhanced MRI does not display bony anatomy as well as CT, but it provides excellent soft
tissue differentiation (53). Bacterial and viral inflammation remains indistinguishable from one another
on MRI, but they are easily differentiated from fungal concretions or neoplasm (4). MRI is the best
modality for delineating extension of disease beyond the paranasal sinuses into the orbits or intracranial
compartment (4). Drawbacks of MRI include longer acquisition time and higher cost (53). IT remains the
diagnostic modality of choice when sinusitis with com- plications is suspected, but MRI is the gold
standard for the diagnosis of intracranial complications (63).

TREATMENT

Antibiotics are the most frequently recommended medications for the treatment of acute rhinosinusitis,
accounting for 21% of antibiotics prescribed for adults and 9% of antibiotics prescribed for children (64-
66). One study showed that physicians ordered, supplied, administered, or continued at least 1
antibiotic in 82.74% of visits for acute rhinosinusitis (65). Antibiotics are prescribed far in excess of the
predicted incidence of ABRS (65). Appropriate antimicrobial use for ABRS requires knowledge of the
natural history of untreated illness and the incremental benefit of antimicrobials on clinical outcomes in
different scenarios (64) (Table 33.7).

Medical Management of Acute Viral Rhinosinusitis

The management of AVRS should be focused on symptom control, as this is a self-limited condition and
there is no evidence that use of medications will help to decrease the potential for conversion into ABRS
(2,3). Analgesic and antipyretic medications will help with pain and fever, two major symptoms
prompting a patient to seek medical care in this clinical scenario (2). Nasal irrigations with hyper- tonic
saline solution have been shown to improve symptoms and reduce the use of pain medications in AVRS
(3,67). They thin mucus and help with mucociliary clearance (42). Decongestant options include systemic
and topical administration, although topical nasal decongestants offer increased symptom relief given
increased potency (2). Although theoretically they may help to restore patency of sinus ostia, this has
not been demonstrated (2). Prescribers must inform their patients of the potential for development of
rhinitis medicamentosa with use prolonged beyond 3 days (2,42). Systemic steroid therapy has not been
shown to be effective for AVRS, and carries a risk of behavioral changes, increased appetite, and weight
gain, even with short courses (2). Topical nasal steroids have minimal systemic absorption and
consequently carry a very low risk for systemic side-effects (2). Yet, there is only weak evidence
supporting their use in AVRS (2). If an allergic component is identified in the clinical presentation, their
use may be more beneficial (2). Antihistamines are another class of medications that may be beneficial if
allergy is suspected to play a role in the disease process. Although the drying effect of antihistamines
may be desirable in certain clinical scenarios, there are no studies demonstrating their capacity to
decrease duration of illness or to decrease the potential of conversion to ABRS (2). Antihistamines,
particularly first-generation, carry risks of drowsiness and behavioral effects. These side effects are seen
less frequently with second-generation antihistamines (2,42). Mucolytics are used to thin mucus in an
attempt to facilitate mucociliary clearance, and their use is shown to decrease symptom scores
compared to placebo (42,65).

Medical Management for Acute Bacterial Rhinosinusitis

For patients presenting with uncomplicated ABRS who have mild illness with mild pain and fever less
than 38.3 ° C (101° F) and in whom there is assurance for follow-up, physicians can limit management to
symptomatic relief and defer antibiotic treatment for up to 7 days after diagnosis (2). The 2007
guidelines emphasize that, ”this observation option is only appropriate if a system is in place that
permits reevaluation if the illness persists or worsens“ (2). Antibiotics are initiated if the patient’s
condition fails to improve by 7 days or worsens at any point during the observation period (2). Although
illness severity largely determines whether a patient is suitable for observation, the clinician must take
into account the overall clinical picture, including the patient’s age and comorbidities when determining
a treatment plan (2).

In cases of uncomplicated mild ABRS, antibiotics can safely be deferred as randomized controlled trials
(RCTs) show that there is a high percentage of spontaneous improvement when patients receive
placebo with only a moderate incremental benefit from the addition of antibiotics (2). In an era of
growing concern about the overdose of antibiotics and resultant problems, including drug resistance
and increasingly virulent bacteria, adherence to these guidelines is encouraged (65). A meta-analysis of
13 RCTs in 2007 shows complete spontaneous clinical cure in 8% of patients at 3 to 5 days after
diagnosis of ABRS (95% CI, 5% to 14%), in 35% at 7 to 12 days (95% CI, 24% to 48%), and 45% by 14 to 15
days (95% CI, 23% to 70%) (64). Rates of spontaneous clinical improvement were 30% at days 3 to 5
(95% CI, 0% to 99%) and 73% at days 7 to 12 (95% CI, 56% to 85%), which remained stable at days 14 to
15 (64). Antimicrobial therapy had no effect on clinical cure at 3 to 5 days after diagnosis of ABRS,
increased absolute cure rates by 15% at days 7 to 12 (95% CI, 4% to 25%) with a number needed to treat
of seven patients, and had no statistical benefit at days 14 to 15 (64). The effects of antibiotics on clinical
improvement rates were very similar to its effects on cure rates (64). This data correlates well with prior
systematic reviews, which showed spontaneous improvement in 62% to 69% of patients after 7 to 14
days after diagnosis of ABRS, spontaneous cure in 19% to 39%, and an absolute increase of 13% to 19%
in favorable outcomes when antibiotics are used (2,64,68-70). Of course, antibiotics are also associated
with side effects and adverse events, which must be taken into account when prescribing them. The
number needed to harm is nine patients, with the most common side effects being gastrointestinal, but
also including skin rash, vaginal discharge, headache, dizziness, and fatigue (64). One analysis estimates
that antibiotics result in 15 days (best case) to 89 days (worst case) of diarrhea, nausea and vomiting, or
both per 100 patients treated with antibiotics for ABRS versus only 8.5 days for those treated with
placebo (2,71).

Symptomatic relief for ABRS is essentially the same as for AVRS. Although one may consider adjunctive
treatments for ABRS including analgesics, antipyretics, nasal saline irrigations, decongestants,
corticosteroids, antihistamines, and mucolytics, none of these therapies has been specifically approved
by the Food and Drug Administration for use in acute rhinosinusitis. Buffered hypertonic saline (3% to
5%) irrigations have shown a modest benefit for ABRS with decreased symptoms and decreased
medication use (2,3). Compared with isotonic saline, the use of hypertonic saline in sinonasal irrigations
may have superior anti-inflammatory effects and better ability to thin mucus, thereby enhancing
mucociliary clearance, although this issue remains controversial (2,3, 72—75). While keeping in mind the
risk of rhinitis medicamentosa, use of topical decongestants is recommended in the management of
ABRS, given improvement in outcomes and reduction of congestion on sinonasal mucosa on MRI seen in
studies (2,76,77). Further, the superior potency of topical decongestant over systemic is depicted by the
decreased congestion appreciated on MRI after topical administration as compared to systemic
administration (77). Trials support the use of topical corticosteroids for ABRS with improved symptom
control in patients, but there is no evidence for the use of systemic glucocorticoids for this illness (2,78
—80). The use of antihistamines in nonatopic patients with ABRS is not supported (2,65). In fact, there is
concern that the cholinergic effects may actually worsen congestion and prolong the infectious process
(2,65). Use of second-generation antihistamines should be limited to patients whose symptoms suggest
an allergic component to their disease process (2,65). Although, in theory, the use of mucolytics would
seem beneficial in airway infections characterized by phlegm and mucus, the literature does not provide
evidence supporting their use in ABRS (2).

Patients who present with ABRS and moderate to severe pain or temperature greater than 38.3 ° C (101°
F) are considered to have severe illness and should be treated initially with oral antibiotics. Ideally, the
antibiotic should be efficacious, cost-effective, and result in minimal side effects (2). Amoxicillin is the
first-line antibiotic recommended for most patients (2,3,42,64,65). Amoxicillin is safe, inexpensive,
efficacious, and has a narrow microbiologic spectrum (2,42) Meta-analysis confirms that treatment with
amoxicillin decreases the duration of symptoms (2,42,64). Comparison of treatment durations of 5 and
10 days does not show a difference in resolution of symptoms, but does show that longer durations of
treatment are associated with an increase in adverse events (2,42, 64). The recommended alternatives
for patients with penicillin allergy are trimethoprim-sulfamethoxazole or a macrolide antibiotic (2,42,
64,65). It is important to remember when prescribing antibiotics that a regimen with simple once daily
dosing for a short duration will have the highest compliance rate (2). Counseling a patient about the
natural history of acute rhinosinusitis, the importance of completing a prescribed antibiotic regimen,
and additional adjunctive measures for symptom control, including hydration and analgesia, is an
important part of treatment planning with your patient (2).

Certain clinical scenarios warrant particular attention

in antibiotic selection. If a patient has been treated with antibiotics in the recent past (4 to 6 weeks),
they are at increased likelihood for infection with a resistant bacterium, and a fluoroquinolone or high-
dose amoxicillin- clavulanate (4 g/250 mg/d) should be used, according to the 2004 Sinus and Allergy
Health Partnership (SAHP) Antimicrobial Treatment Guidelines (2,42,81). In the SAHP Guidelines,
amoxicillin-clavulanate had the highest calculated clinical efficacy in both the groups that had and those
that had not recently received antibiotics (65). Patients with young children in daycare are at risk for
penicillin-resistant S. pneumoniae infection, and high-dose amoxicillin should be considered in this group
(42,65). The SAHP Guidelines show that, in decreasing order of efficacy, other antibiotics that can be
used for treatment of ABRS are cefpodoxime proxetil, cefuroxime axetil, cefdinir, trimethoprim-
sulfamethoxazole, doxycycline, and azithromycin, clarithromycin, or erythromycin (65,81). This is an
important list, especially given that a study in 2002 showed the second most frequently prescribed class
of antibiotics for ABRS behind penicillins (including amoxicillin and amoxicillin-clavulanate) was the
group including erythromycins, lincosamides, and macrolides (65). An antibiotic from this group was
prescribed in 24.32% of visits for ABRS, ahead of cephalosporins, sulfonamides and trimethoprim, and
tetracyclines, which all have demonstrated increased efficacy for this illness (65).

Management for Patients Who Have Failed

Primary Treatment of ABRS

The most recent treatment guidelines from 2007 recommend using 7 days as a cut-off point after initial
diagnosis to assess for treatment failure (2). Treatment failure entails worsening, defined as progression
of presenting signs or symptoms or onset of new symptoms or signs, and failure to improve, defined as
lack of reduction in presenting signs or symptoms of ABRS (2). Failure to improve, therefore, would not
be diagnosed in a patient undergoing treatment for ABRS who has persistent, but slowly resolving
symptoms of ABRS. Seven days is chosen as the cut point based on studies showing that between 7 and
12 days after diagnosis 73% of patients randomized to placebo and 85% of patients receiving antibiotics
have clinical improvement (2,64). At 3 to 5 days after diagnosis, only 30% of patients receiving placebo
and 41% of patients taking antibiotics have clinical improvement, thus a cut point at 5 days would
include many false positives (2, 64). If a patient fails treatment at the 7-day mark, they should be
reevaluated for complications of ABRS, drug-resistant bacteria, or non- bacterial cause (2). If the patient
was initially managed with observation, the clinician should begin treatment with amoxicillin or an
appropriate alternative in patients with penicillin allergy (trimethoprim-sulfamethoxazole or macrolide
antibiotic) (2). Patients who have been taking an antibiotic, such as amoxicillin, and who have treatment
failure are more likely to be infected with reduced susceptibility bacteria (2). Organisms that should be
suspected, particularly in a patient with previous antibiotic therapy, are beta-lactamase producing H.
influenzae or M. cataihalis and S. pneumoniae with reduced susceptibility to beta-lactams, macrolides,
tetracyclines, and trimethoprim-sulfamethoxazole (2). Optimal antibiotic therapy recommended by the
2007 Guidelines for ABRS treatment failures are high-dose amoxicillin-clavulanate (4 g/d) or a
respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin) (2). Cephalosporins and
macrolides are predicted to offer inadequate coverage (2).

Management of Acute Fulminant

Invasive Fungal Sinusitis—Medical and Surgical

The management of acute fulminant invasive fungal sinus- itis necessitates combined medical and
surgical modalities with a multidisciplinary approach. Systemic antifungal therapy with amphotericin or
voriconazole is necessary, but alone not sufficient to treat this condition (40). Early aggressive
endoscopic sinonasal debridement of all involved tissue is necessary for any patient with biopsy- proven
disease or in anyone in whom there is high clinical suspicion. The goals of debridement include
reduction of the fungal load, slowing progression of disease, and obtaining a specimen for culture and
sensitivity studies (40). Many patients affected by this disease will inherently have thrombocytopenia or
coagulopathy as part of their underlying condition. This must be addressed with platelet and factor
transfusion pre- and intraoperatively in order to minimize hemorrhage (40). Adjunctive measures to
tackle this disease involve strategies to correct the underlying immune deficit, such as correction of
diabetic ketoacidosis, transfusion of white blood cells, or administration of granulocyte colony-
stimulating factor (40). The mortality rate for this condition approaches 100% if there is symptomatic
intracranial involvement, but overall is about 20% (41,82). Mortality is also strongly related to the
underlying condition, with diabetics having significantly higher mortality (40%) than patients with
hematologic malignancy (11%) (82). This disparity is likely due to a greater incidence of Mucormycosis
over Aspergillus in diabetic patients, with the reverse true in patients with hematologic malignancy, and
a delay in diagnosis in diabetic patients resulting in more advanced disease at the time of diagnosis (82).

COMPLICATIONS
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. Despite widespread use of antibiotics and reactionary concerns
about their overuse in ABRS, a small but significant percentage of patients still develop adverse sequelae
of acute rhinosinusitis, and specifically of ABRS.

Several factors have been identified as risk factors for development of complications from ABRS. The
majority of patients admitted for complications secondary to ABRS present in the winter months, from
January through March (83). This seasonal incidence is likely secondary to an increased incidence of viral
infections in the fall and winter (83). In the pediatric population, the highest risk age group for hospital
admission due to complications of ABRS is 3 to 6 years of age (83). However, among pediatric patients
admitted with orbital complications of ABRS, those most at risk for intracranial extension are age 7 years
or older (40). In adults, intracranial extension is more commonly seen in patients with a history of
chronic rhinosinusitis (40,84,85). However, in the pediatric population, intracranial involvement almost
exclusively occurs in the setting of ABRS (40,86-89). Overall, the highest risk group for intracranial
complications are males during adolescence and young adulthood (10 to 29 years old) (40,86,90,91). It
has been suggested that this age group is disproportionately affected because this is the age at which
the valueless diploic system is at its most vascular, there- fore providing a good conduit for propagation
of bacterial infection (40,86,92). Additionally, it is thought that the maturing posterior table of the
frontal sinus is a poor barrier to spread of organisms (86). Infants are at particular risk for the
development of meningitis because, as opposed to the efficient barrier to infection provided by the
mature arachnoid mater, bacteria are freely transmitted across the immature arachnoid layer (40,93).
Additional information regarding Complications of Rhinosinusitis may be found in Chapter 38.

Extracranial Complications

A relatively benign sequela of acute rhinosinusitis is anosmia. Acute rhinosinusitis accounts for 18% to
36% of anosmia (94). While transient hyposmia is common in acute rhinosinusitis, permanent anosmia
may also occur, though rarely (51). Women are disproportionately affected, comprising 67% of patients
presenting with viral-induced olfactory loss in one study (51). Two recent studies show promising results
with improvement in olfaction in over 80% of patients with sensorineural deficits in olfaction, including
those related to acute rhinosinusitis, treated with systemic steroids (94,95).

Pott puffy tumor (PPT), first described by Sir Percivall

Pott in 1775, is a subperiosteal abscess of the frontal bone associated with frontal osteomyelitis (40,96).
The pathophysiology occurs as bacterial infection, most commonly S. aureus, nonenterococcal
streptococcus, and oral anaerobes, often polymicrobial, spreading from the frontal sinuses into the
frontal bone causing inflammation and suppuration of the valueless diploic veins, which propagates to
the Haverian system of the inner and outer tables of the skull, resulting in localized demineralization and
necrosis (40). This ultimately results in perforation of the frontal sinus anterior table, facilitating the
subperiosteal pus collection and formation of granulation tissue that characterizes PPT (40). This entity
is managed with a combined surgical and medical approach.
Orbital extension of acute rhinosinusitis is the most common complication in both pediatric and adult
populations (40,83). In the preantibiotic era, 17% of patients with orbital infection died of meningitis
and 20% became blind in the affected eye (83,97). By 1991, the incidence of blindness had fallen to
10.5%, and in a pediatric study from 2009 reviewing 157 orbital complications of ABRS, the incidence of
subsequent blindness was 0.6% (83,98). The Chandler classification for orbital complications of
rhinosinusitis was introduced in 1970 (97). The strength of this system is its organization as a
progression of pat- terns that describes the pathogenesis of orbital extension of ABRS from preseptal
cellulitis (I) to postseptal cellulitis (II), and ultimate progression to subperiosteal abscess (III) and finally
orbital abscess (IV) (97). Preseptal or periorbital cellulitis (class I) is the most common of the orbital
complications in all age groups (70%) (40). The drawback of this classification scheme is its omission of
the most advanced stages of orbital inflammation, including orbital apex syn- drome, retrobulbar
phlegmon, retrobulbar abscess, and cavernous sinus thrombosis which may also develop as a result of
complications of acute rhinosinusitis (83).

Management of secondary orbital involvement is determined according to the Chandler stage of

disease. All patients need antibiotics. For patients with preseptal cellulitis over 3 years of age in whom
there is assurance of follow-up, treatment may be with broad-spectrum oral antibiotics, head elevation,
warm compresses, topical decongestant, and saline irrigations (40,83). For more advanced disease,
empiric IV antibiotic management may begin with high-dose beta-lactamase antibiotics, with cognizance
of possible resistance, or a third-generation cephalosporin (83). Most preseptal and postseptal cellulitis
(grade I and II) can be successfully managed medically (83). Indications for surgical intervention include:
in stage I or II disease if the patient’s condition fails to improve significantly within 24 to 48 hours of
appropriate antibiotic administration so that cultures may be obtained to direct antibiosis, immediately
if visual acuity worsens, if the patient develops increasing proptosis and/or ophthalmoplegia, and if an
abscess is demonstrated on if (83). Subperiosteal abscesses must be evaluated individually, and the
treatment plan should be tailored to the specific clinical situation. The recommended criteria for
medical management of medial subperiosteal abscesses are normal vision, pupil, and retina, no
ophthalmoplegia, intra- ocular pressure of less than 20 mm Hg, proptosis of 5 mm or less, and abscess
width of 4 mm or less (40,99). These patients will need attentive monitoring, and if they have any
deterioration or fail to improve clinically within 48 to 72 hours, they will likely require repeat imaging
and surgical intervention (40,83,99, 100). Surgical intervention for secondary orbital involvement
includes endoscopic sinus surgery to drain the affected sinuses and obtain cultures.

The extent of surgery is dictated by the degree of sinus involvement (83). The approach to an abscess, if
present, depends on its location within the orbit. Many sub- periosteal abscesses, particularly in young
children, are along the medial orbital wall due to extension from the ethmoid sinuses and can be
drained at the time of endoscopic ethmoidectomy (83,101). The main limitation with an endoscopic
approach in the acute setting is potential for increased bleeding, which could compromise visualization
(40). If this is a concern, a traditional Lynch incision can be considered to approach the medial orbital
abscess and to perform external ethmoidectomy (40). An abscess that is lateral, superior, or inferior
within the orbit will likely require external orbitotomy for drainage (83). Although often involved in
surgical intervention for lesser degrees of orbital infection, ophthalmologists are integral while
addressing an intraconal abscess (40).
Intracranial Complications

Intracranial complications affect between 0.5% and 24% of patients admitted to the hospital with
rhinosinusitis (86,102,103). The intracranial complications include meningitis, extradural abscess,
subdural empyema, intracerebral abscess, and cavernous and superior sagittal sinus thrombosis (86)
(Fig. 33.2A and B). Their relative frequencies have been disputed in the literature (86). Infection of the
paranasal sinuses can spread to the intracranial compartment directly via osteomyelitis of the skull, by
retrograde thrombophlebitis and septic emboli, or through a post- traumatic, congenital, or postsurgical
defect that connects the sinuses with intracranial contents (86). The proportion of brain abscesses
secondary to either an otologic or sinogenic origin has been estimated at nearly two-thirds, and
although historically this predominantly comprised otologic etiology, literature suggests that sinogenic
cause has become nearly as common (86,102,104—106). Despite advances in imaging techniques
facilitating early detection as well as pharmaceutical and surgical developments, the morbidity and
mortality of intracranial complications have remained stable since the 1980s at 5% to 21% and up to
40%, respectively (86,103—106). Morbidities include long-term neurologic deficits, cognitive
impairment, cranial nerve palsy, aphasia, epilepsy, hydrocephalus, and visual and hearing loss (40).

SPECIAL CONSIDERATIONS IN THE PEDIATRIC POPULATION

Pediatric patients are particularly susceptible to all infections given their evolving and maturing immune
system. They frequently experience six to eight episodes of upper respiratory infection annually, as
compared to the average one to three for adults (30). Given an average conversion of AVRS into ABRS of
0.5% to 2%, they are statistically projected to have more ABRS than adults. A large retrospective review
of 339 pediatric patients admitted to the hospital for treatment failure of ABRS identified the peak age-
group for treatment failure between 3 and 6 years of age (83) This is potentially explained with a
correlation to the age of first attendance at daycare, preschool, and kindergarten, with concomitant first
exposure to pathogens that cause acute rhinosinusitis (83).

The patterns of complications from ABRS in the pediatric population are explained by sinus development
and maturation during childhood. The maxillary sinus and ethmoid labyrinth are present at birth.
Because orbital complications of sinusitis are frequently associated with ethmoid sinusitis, young
children are particularly susceptible to orbital extension of disease (83). The sphenoid sinuses are
frequently pneumatized by age 5, but the frontal sinuses don’t appear until age 7 or 8. Over the next 5
or so years, the frontal sinuses pneumatize and mature, and accordingly intracranial complications,
particularly related to the frontal sinuses, are seen most often in the preteen and adolescent years of life
(83).

CONCLUSION

Although otolaryngologists are not frequently the ones providing care for uncomplicated AVRS and
ABRS, it is important to be familiar with this disease process. Acute rhinosinusitis is common and has an
associated tremendous economic impact. Adherence to guidelines in the treatment planning and follow-
up evaluation of patients with acute rhinosinusitis will hopefully help to minimize the eco- nomic and
quality of life burden associated with this dis- ease, in addition to avoiding future patterns of multidrug
resistant, increasingly virulent bacteria. Familiarity with the diagnosis and management of the life-
threatening complications of ABRS is necessary as the otolaryngologist will certainly be involved in the
care of the patient at that point.

HIGHLIGHTS

Rhinosinusitis is a common illness with a large economic burden in the United States.

The most common infectious cause of acute rhinosinusitis is viral illness. Less than 5% of viral illnesses
transition into an ABRS. When ABRS does occur, the most common bacterial pathogens are S.
pneumoniae, M. catarrhalis, and H. influenzae.

The three cardinal symptoms of ABRS are purulent nasal discharge, nasal obstruction, and/or facial pain,
pressure, or fullness. ABRS is diagnosed when the three cardinal symptoms are present for 10 or longer
beyond the onset of upper respiratory symptoms or when there is a double-worsening of symptoms
within 10 days of illness onset.

Sinonasal endoscopy is indicated in ABRS for symptomatic patients who fail to improve on empiric
therapy, who have unilateral disease, who have severe or disabling symptoms, in whom complications
are suspected, or who are immunocompromised and consequently at risk for complications.

CT of the sinuses is recommended when a complication of ABRS is suspected or an alternative diagnosis

is considered. It may also be used when patients have comorbidities that predispose to complications.
MRI is the gold standard imaging modality for diagnosis of intracranial extension of sinusitis.

The recommended management for acute viral rhinosinusitis is analgesia and antipyretics, saline
irrigations, and topical decongestants for 3 days or less. Topical corticosteroids can be used in addition
to mucolytics or second- generation antihistamines if clinically indicated.

The first-line antibiotic for ABRS is amoxicillin. For patients with penicillin allergy, first-line alternatives
are trimethoprim—sulfamethoxazole or macrolides. Patients who have had antibiotics within 4 to 6
weeks prior or who have young children in daycare may be at increased risk for infection with resistant
bacteria, and should receive high-dose amoxicillin, high-dose amoxicillin-clavulanate, or
fluoroquinolone.

The possible clinical outcomes for ABRS are resolution, development of complications, or development
of chronic rhinosinusitis. The risk factors for development of sequelae of ABRS are male gender, age 10
to 29 years old, and illness during the winter months.

The most common complication of ABRS in all age groups is orbital extension of disease, which includes
the spectrum of illness from preseptal cellulitis through orbital abscess. There is a risk of blindness with
extension of infection into the eye.

Intracranial complications include meningitis, extradural abscess, subdural abscess, intraparenchymal

abscess, and cavernous and superior sagittal sinus thrombosis. These have a high risk for associated
morbidity and mortality and require aggressive multidisciplinary approach to management.