SINUSITIS

Classification (By duration)

  • Acute sinusitis

Duration less than 4 weeks (1)

  • Further classified based on presumed cause 2
    • Acute viral sinusitis
    • Acute bacterial sinusitis
    • Chronic sinusitis
  • Duration more than 12 weeks, with or without acute exacerbations 2 7
    • Recurrent acute sinusitis
  • 4 or more episodes of acute bacterial sinusitis per year, without persistent symptoms in between (2)

Symptom

Comunes

  • Nasal congestion
  • Purulent rhinitis
  • Facial pain or pressure
  • Headache
  • Maxillary toothache
  • Persistent cough (usually with a more severe nocturnal component)
  • Postnasal drip
  • Poor response to decongestants
  • In children, increased irritability and vomiting may be present as a result of gagging on mucus and prolonged cough

Menos Comunes

  • Fever (more common in children)
  • Nausea
  • Malaise
  • Fatigue
  • Halitosis
  • Sore throat

Signs

  • Tenderness over the involved sinus cavities is sometimes present
  • Periorbital edema present in patients with cellulitis
  • Dark circles under eyes (may reflect allergic diathesis more than infection)
  • Absence of transillumination
  • Mucous membrane edema
  • Increased posterior pharyngeal secretions
  • Purulent secretions from middle meatal region

Etiology

  • Acute viral infection
  • Majority (up to 90%) of viral upper respiratory tract infections have concurrent acute viral sinusitis.  Only 0.5% to 2% of cases have sinusitis that progresses to acute bacterial sinusitis. (3)
  • Acute bacterial infection
    • Streptococcus pneumoniae and other Streptococcus species. (4)
    • Nontypable Haemophilus influenzae (1)
    • Moraxella (Branhamella) catarrhalis
    • Staphylococcus aureus
    • Anaerobes (Peptostreptococcus, Fusobacterium, Bacteroides, and Prevotellaspecies)

How to distinguish between Viral and Bacterial?

Viral

  • Defined as up to 4 weeks of purulent nasal drainage with nasal obstruction; facial pain, fullness, or pressure; or both
  • Presence of purulent nasal discharge alone does not indicate bacterial infection; coloration is due to the presence of neutrophils, a sign of inflammation, and not specific for infection
  • Presume diagnosis of viral sinusitis when signs and symptoms of acute sinusitis are present for less than 10 days and not worsening

Bacterial

  • Adults:
    • Signs and symptoms of acute sinusitis that persist for at least 10 days without improvement or worsen within 10 days after initial improvement. (5)
  • Children:
    • Persistent symptoms of upper respiratory tract infection, including nasal discharge and cough, for longer than 10 days without improvement
    • Worsening course, such as worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement
    • Severe onset, including temperature of at least 39°C and purulent nasal discharge for at least 3 consecutive days

Differential diagnosis

  • Infeccion Respiratoria Alta (IRA)
  • Rinitis Alergica
  • Rinitis No-alergica
  • Poliposis Nasal
  • Granulomatosis de Wegener:
  • Chronic granulomatous inflammatory disease of the upper and lower respiratory tracts occurs simultaneously with glomerulonephritis
  • Granulomatous invasion destroys the nasal septum, erodes nasal cartilage, and can cause proptosis in advanced cases

Imaging

  • Not required in most cases of acute uncomplicated sinusitis. Sinus radiographs are often inaccurate and have been largely supplanted by CT when imaging is necessary: (6)
    • Sinus CT (without contrast enhancement) provides best definition of bone integrity or erosion
    • CT with contrast enhancement may be used as alternative to MRI
  • Indications include:
    • Evaluation of patients with clinical concern for intraorbital or intracranial complications of sinusitis
    • Evaluation of recurrent acute sinusitis before surgical intervention
    • Confirmation of chronic sinusitis
    • Providing preoperative anatomical information
  • Abnormal results include:
    • Moderate to severe mucosal thickening in the sinuses caused by inflammation
    • Loss of air-space volume in the sinuses caused by mucus accumulation
    • Opacification as a result of increased air-fluid levels in the paranasal sinuses
    • Mucus retention cysts causing swelling in the sinuses

Treatment

  • In most patients, symptoms of acute sinusitis will resolve themselves within 1 to 2 weeks; supportive therapy only (eg, analgesic medications, nasal sprays, decongestants) is recommended in most cases
  • If acute uncomplicated bacterial sinusitis is suspected, offer patient choice of watchful waiting (without antibiotics) or prescribe initial antibiotic therapy. (7)

In adults (older than 18 years):

  • Consider offering up to 7 days of outpatient observation after diagnosis of acute bacterial sinusitis before initiating antibiotic treatment
  • Begin antibiotic treatment if patient worsens at any time or condition fails to improve by 7 days

In children (ages 1-18):

  • With persistent illness, consider offering additional outpatient observation for 3 days before starting treatment
  • With severe onset or worsening course, initiate antibiotic therapy

If  bacterial sinusitis is suspected the recommends empiric antiobiotic therapy at the time of presentation under the following circumstances: (8)

  • A clinical presentation of severe symptoms or worsening symptoms
    • severe: fiebre > 102.2F and purulent nasal discharge for >3 days
    • worsening: sintomas respiratorios que se empeoran luego de haber mejorado, o nueva fiebre o cefalea severa.
  • Complications or suspected complications
  • Receipt of antibiotic therapy in the previous four weeks
  • Concurrent bacterial infection (eg, pneumonia, suppurative cervical adenitis, group A streptococcal pharyngitis, acute otitis media)
  • Certain underlying conditions, including asthma, cystic fibrosis, immunodeficiency, previous sinus surgery, or anatomic abnormalities of the upper respiratory tract

Symptom Management

  • Analgesics
    • (eg, acetaminophen or NSAIDs) can relieve pain and fever
  • Nasal saline irrigation
    • May improve quality of life, decrease symptoms, and decrease medication use, especially in patients with frequent sinusitis
    • Either physiologic or hypertonic saline can be used to clean debris from the nasal cavity and promote drainage; hypertonic saline can also temporarily reduce tissue edema
  • Topical intranasal corticosteroids
    • May reduce edema around sinus ostia and encourage drainage, relieving nasal congestion and facial pain (9)
    • Minor adverse events include epistaxis, headache, and nasal itching
  • Decongestants (topical and systemic):
    • while frequently used, are not specifically recommended as adjunct treatment in patients with acute bacterial sinusitis
    • Topical decongestant use may be palliative by reducing congestion of sinus and nasal mucosa; duration of use should not exceed 3 to 5 days to avoid rebound congestion and medicamentous rhinitis
    • Oral decongestants may provide symptomatic relief; can be considered if no medical contraindications exist
  • Antihistamines
    • have no role in symptomatic relief of acute sinusitis; no studies support their use in an infectious setting, and they may worsen congestion by drying nasal mucosa (10)
  • Guaifenesin
    • an expectorant used to loosen phlegm and bronchial secretions; evidence of clinical efficacy is lacking and decisions regarding use are based patient and provider preference
  • Antibioticos

Usually empiric; some common antibiotics are no longer empirically recommended owing to resistance: (11)

  • Macrolides (eg, clarithromycin, azithromycin): not recommended for empiric therapy owing to high rates of Streptococcus pneumoniae resistance
  • Trimethoprim-sulfamethoxazole: not recommended for empiric therapy because of high rates of resistance among both Streptococcus pneumoniae and Haemophilus influenzae
  • Second- and third-generation oral cephalosporins: no longer recommended for empiric monotherapy owing to variable rates of resistance among Streptococcus pneumoniae
    • If an oral cephalosporin is to be used (eg, for patients from geographic areas with high endemic rates of penicillin-nonsusceptible Streptococcus pneumoniae or with non–type I penicillin allergy), a third generation cephalosporin (eg, cefixime, cefpodoxime) in combination with clindamycin is recommended
  • First line empiric therapy is amoxicillin (amoxicillin–clavulanic acid may be preferable), which is generally effective, inexpensive, and well tolerated
  • Amoxicillin Oral Suspension: Standard dose
    • Children and Adolescents 2 years and older (standard-dose therapy): 45 mg/kg/day PO divided every 12 hours is standard dose for children with mild/moderate uncomplicated disease (do not attend daycare, have not had antibiotics in last 4 weeks).
  • Amoxicillin Oral Suspension: High dose
    • Children and Adolescents 2 years and older (high-dose therapy): 80 to 90 mg/kg/day PO in divided doses every 12 hours (Max: 2 g/dose) is recommended for children in areas with high rates of S. pneumoniae resistance (more than 10%, including intermediate- and high-level resistance). Use high-dose amoxicillin; clavulanic acid for those with moderate/severe disease, attending daycare, or who have recently been treated with antimicrobial therapy.
  • Amoxicillin/Clavulanate Oral suspension: Standard dose
    • Neonates and Infants 1 to 2 months: 30 mg/kg/day amoxicillin component PO divided every 12 hours; only 125 mg/5 mL suspension recommended in this age group. IDSA recommends to treat for 10 to 14 days.
    • Infants 3 months and older, Children, and Adolescents weighing less than 40 kg: 45 mg/kg/day amoxicillin component PO divided every 12 hours (using 200 mg/5 mL or 400 mg/5 mL suspension; 200 mg or 400 mg chewable tablets) or 40 mg/kg/day amoxicillin component PO divided every 8 hours (using 125 mg/5 mL or 250 mg/5 mL suspension; 125 mg or 250 mg chewable tablets; or 500 mg regular tablets) for 10 to 14 days; every 12 hour regimen preferred because it causes less diarrhea.
    • Children and Adolescents weighing 40 kg or more: 875 mg amoxicillin with 125 mg clavulanic acid PO every 12 hours (using 875 mg tablet or 200 mg/5 mL or 400 mg/5 mL suspension) or 500 mg amoxicillin with 125 mg clavulanic acid PO every 8 hours (using 500 mg regular tablets; 125 mg or 250 mg chewable tablets; or 125 mg/5 mL or 250 mg/5 mL suspension) for 10 to 14 days.
  • Amoxicillin/Clavulanate: High dose
    • Oral suspension; Infants, Children, and Adolescents: 90 mg/kg/day amoxicillin component PO divided twice daily for 10 to 14 days (Max: 2000 mg amoxicillin/125 mg clavulanic acid twice daily).
    • Oral tablet, extended-release; Children and Adolescents weighing 40 kg or more: 2000 mg amoxicillin with 125 mg clavulanic acid PO every 12 hours for 10 to 14 days.
    • Oral tablet, extended-release; Adults: 2000 mg amoxicillin with 125 mg clavulanic acid PO every 12 hours for 10 days per FDA-approved labeling. IDSA recommends to treat for 5 to 7 days.
    • High-dose amoxicillin-clavulanate therapy is recommended as initial empiric therapy in the following settings:
      • Severe infection (eg, systemic toxicity with fever 39°C or higher)
      • Risk factors for resistance (eg, day care attendance, age younger than 2 years or older than 65 years, recent hospitalization, antibiotic use within past month, immunocompromised state)
      • High endemic rate (10% or higher) of penicillin-nonsusceptible Streptococcus pneumoniae
  • Second Line therapies
    • Doxycycline
      • Doxycycline Oral suspension; Children 8 years and older and Adolescents weighing less than 45 kg: 2.2 mg/kg/dose PO every 12 hours on day 1, then 2.2 mg/kg/day, or for severe infections, every 12 hours.
      • Doxycycline Oral tablet; Children 8 years and older and Adolescents weighing 45 kg or more: 100 mg PO every 12 hours on day 1, then 100 mg/day, or for severe infections, every 12 hours.
      • Doxycycline Oral tablet; Adults: 100 mg PO every 12 hours on day 1, then 100 mg/day, or for severe infections, every 12 hours. For sinusitis, clinical guidelines recommend 100 mg PO twice daily or 200 mg/day PO for 5 to 7 days as second line therapy or for beta-lactam allergy.
  • Quinolones (Levofloxacin)
    • Alternative for penicillin-allergic patients with no other treatment options
    • Note: systemic fluoroquinolones have been associated with disabling and potentially irreversible serious adverse effects involving the central nervous system, nerves, tendons, muscles, and joints. Reserve for use in patients who have no other treatment options for acute bacterial sinusitis. Benefits may outweigh risks for some serious bacterial infections, and it is appropriate for them to remain available as a therapeutic option. (12)
    • Levofloxacin Oral tablet; Adults: 500 mg PO once daily for 5 to 7 days recommended by clinical guidelines as alternative therapy; FDA-approved dose is 500 mg PO every 24 hours for 10 to 14 days or 750 mg PO every 24 hours for 5 days. Due to the risk for serious and potentially permanent side effects, only use in cases where alternative treatment options cannot be used.
  • Cefixime
    • Used in combination therapy with clindamycin as second line therapy for children with non–type 1 penicillin allergy or from geographic regions with high endemic rates of penicillin nonsusceptible Streptococcus pneumoniae 6
    • Cefixime Oral suspension; Infants 6 months and older, Children, and Adolescents: 8 mg/kg/day PO divided every 12 hours (Max: 400 mg/day) with clindamycin for 10 to 14 days; IDSA does not recommend as monotherapy, but may be given as second-line therapy with clindamycin.
  • Clindamycin
    • Used to treat sinusitis caused by both staphylococci and anaerobes
    • May be added to a broad-spectrum antibiotic agent for anaerobic coverage in chronic sinusitis
    • Used in combination therapy with cefixime as second line therapy for children with non–type 1 penicillin allergy or for patients from geographic regions with high endemic rates of penicillin nonsusceptible Streptococcus pneumoniae
    • Clindamycin Oral capsule; Infants, Children, and Adolescents: 30 to 40 mg/kg/day PO divided every 8 hours (Max: 1,800 mg/day) in combination with cefixime (4 mg/kg/dose PO twice daily) or cefpodoxime (5 mg/kg/dose PO twice daily) for 10 to 14 days; recommended as second-line therapy for children with a non-type I penicillin allergy or from regions with high rates of penicillin-nonsusceptible S. pneumoniae.
    • Clindamycin Oral capsule; Adults: 300 mg PO 3 times per day in combination therapy with cefixime. (13)
  • Penicillin-allergic patients
  • For penicillin-allergic adults: alternatives for empiric treatment include doxycycline (preferred) or a respiratory fluoroquinolone; combination therapy with clindamycin plus a third-generation oral cephalosporin (eg, cefixime, cefpodoxime) is recommended in adults with a history of non–type I hypersensitivity to penicillin
  • For penicillin-allergic children: combination therapy with a third-generation oral cephalosporin (eg, cefixime, cefpodoxime) plus clindamycin may be used as alternative for children with non–type I penicillin allergy; levofloxacin is recommended for those with a history of type I hypersensitivity to penicillin 6
  • Duration of therapy is inconsistent in the literature; recommendations based on clinical observations vary widely
    • In adults: treatment can range from 5 to 10 days; No consistent benefit demonstrated in 10 days of therapy versus shorter courses.  Consider longer course for more severe illness or when symptoms persist despite shorter course. (14)
    • In children: treatment duration ranges from 10 to 28 days (often 10-14 days)
  • Treatment failure
  • Consider in a patient initially treated with antimicrobial agents
    • In adults: condition worsens or fails to improve with initial management option by 7 days after diagnosis or worsens during initial management
      • Fluctuations of signs and symptoms during first 48 to 72 hours of initial therapy are not uncommon, and do not necessarily indicate treatment failure
    • In children: worsening of symptoms or condition fails to improve in 72 hours
  • The Infectious Diseases Society of America suggests alternative treatment strategy if symptoms worsen after 72 hours or condition fails to improve despite 3 to 5 days of initial empiric antimicrobial therapy. (15)
  • Reassess patient to confirm diagnosis, exclude other causes, and detect complications
  • If sinusitis remains the best diagnosis, change antimicrobial agent

Terapias Adicionales (to aid mucociliary clearance)

  • Nasal saline irrigation is more effective than nasal sprays in patients with chronic sinusitis (16)
  • Humidification therapy: inhaled steam (eg, from a hot shower) may provide symptomatic relief
  • Application of warm facial packs may provide symptomatic relief
  • Lifestyle changes (eg, smoking cessation, avoidance of allergens) may help prevent recurrence.

Socio cultural aspect

The use of alterantive medicins, is closely linked to the culture and personal beliefs. For example, Ayurvédica Medicine is used in rural areas of India in 65%, 70% of people in Canada and 49% of people in France use alternative therapies.

The medicinal herbs were the group of remedies most used. A possible explanation for this may be the access, and the cost of these remedies. For example, is posible to find many of these products in most domestic kitchens, such as cumin, fennel, garlic, ginger, honey, lime, lemon, mint, plantain, parsley, eucalyptus and turmeric.

The most common remedies are products of local origin; for example, in Bangladesh, the parents use warm milk with leaves of the Tulshi plant; In India, the parents use Kashiphal (a type of pumpkin that is grown in India); In Ethiopia, they use the leaves of the local eucalyptus tree. The principal reasons to use these alternative therapies, indicate the studies are the parents who inclined to use plant or medicinal food in the treatment of infant airways as a drugs. African and Latin American migrants are living in Europe or the United States continue use the remedies they learned in their countries of origin.

Interestingly, the use of medicinal herbs are in 80% of the Latin American population for upper respiratory infection in children, it was not studied, Different of the European, American and Asian plants which studies promoted by the pharmaceutical houses that determined an efficacy Level I, for plants such as Echinacea spp (American flower). Hedera helix, Sambucus nigra, black sauce, andrographis paniculata, Allium ursinum, wild garlic or bear garlic), as well as probiotics, which are sold in the form of syrups, capsules and pills by pharmaceutical houses at high prices.

Health professionals, to treat the respiratory infections in children, need consciences of use the medical alternatives and rejection of parental drugs. The frequency of use of alternative medicine is 8 out of 10 patients, is this the reality despite the part of doctors and patients.

BIBLIOGRAPHIC REFERENCES

1. Pappas DE et al: Sinusitis. In: Kliegman RM, ed: Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:2014-7
2. Rosenfeld RM et al: Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 152(2 Suppl):S1-S39, 2015
3. Rosenfeld RM: Clinical practice. Acute sinusitis in adults. N Engl J Med. 375(10):962-70, 2016
4. DeMuri GP et al: Sinusitis. In: Bennett JE et al, eds: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, Updated Edition. 8th ed. Philadelphia, PA: Saunders; 2015:774-84
5. Rosenfeld RM: Clinical practice. Acute sinusitis in adults. N Engl J Med. 375(10):962-70, 2016
6. Expert Panel on Neurologic Imaging et al: ACR Appropriateness Criteria: sinonasal disease. J Am Coll Radiol. 14(11S):S550-9, 2017
7. Expert Panel on Neurologic Imaging et al: ACR Appropriateness Criteria: sinonasal disease. J Am Coll Radiol. 14(11S):S550-9, 2017
8. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013; 132:e262.
9. Urdaneta ER, Tunceli K, Gates G. Mometasone furoate nasal spray relieves moderate-severe nasal congestion in patients with seasonal allergic rhinitis: a responder analysis. Presented at: AAAAI/WAO Joint Congress; March 2-5, 2018; Orlando, FL. Abstract 217
10. Seresirikachorn, K., Khattiyawittayakun, L., Chitsuthipakorn, W., & Snidvongs, K.. Antihistamines for treating rhinosinusitis: Systematic review and meta-analysis of randomised controlled studies. The Journal of Laryngology & Otology, 2018. 132(2), 105-110.
11. Chow AW et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 54(8):e72-e112, 2012
12. FDA: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication – Warnings Updated Due to Disabling Side Effects. FDA website. Updated March 8, 2018. Accessed Sept. 11, 2018.   https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm
13. Rosenfeld RM: Clinical practice. Acute sinusitis in adults. N Engl J Med. 375(10):962-70, 2016
14. Rosenfeld RM et al: Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 152(2 Suppl):S1-S39, 2015
15. Chow AW et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 54(8):e72-e112, 2012
16. https://www.cochrane.org/CD011995/ENT_saline-irrigation-chronic-rhinosinusitis. Apr 26, 2016
17. S. Lucas, M. Leach and S. Kumar Complementary and alternative medicine utilisation for the management of acute respiratory tract infection in children: A systematic review Complementary Therapies in Medicine, 2018-04-01, Volume 37, Pages 158-166, 2018 Elsevier