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Acute Rhinosinusitis and Infectious Complications
Key Points
- 1.
Antibiotics are frequently administered to treat acute rhinosinusitis. Guidelines for appropriate antibiotic use should be followed.
- 2.
Infectious complications of rhinosinusitis extending beyond the paranasal sinuses are rare. These include orbital, intracranial, and, less commonly osseous complications.
- 3.
Acute invasive fungal sinusitis must be suspected in immunocompromised patients with acute, rapidly progressive disease and must be managed expeditiously.
Pearls
- 1.
Acute rhinosinusitis is more commonly viral than bacterial, especially within the first 10 days of symptoms.
- 2.
The Chandler classification for orbital extension of rhinosinusitis is used to categorize infections: I, preseptal cellulitis; II, orbital cellulitis; III, subperiosteal abscess; IV, orbital abscess; and V, cavernous sinus thrombosis.
- 3.
Acute intracranial complications of the frontal lobe may result from the spread of infection through the venous channels directly communicating with the frontal sinus.
Questions
1
How is acute rhinosinusitis (ARS) defined?
ARS is a symptomatic inflammation of the nasal cavity and paranasal sinuses for up to 4 weeks. The most common causes of this condition are viral and bacterial infections, with viral etiologies predominating in the first 10 days. Symptoms include nasal congestion, postnasal drainage, facial pain/pressure, decreased olfaction, sore throat, hoarseness, cough, and/or fever. Recurrent acute rhinosinusitis (RARS) is defined as four or more episodes of acute bacterial rhinosinusitis (ABRS) annually; all episodes must meet the criteria for ABRS.
2
What is the pathophysiology of ARS?
Inflammation of the nasal and paranasal sinus mucosa with subsequent edema is an initiating factor in this disease. Most often this inflammation is caused by viral infections and/or allergic rhinitis. This edema can cause obstruction of normal sinus drainage, impaired mucociliary clearance, and altered local immune system function. These changes create an ideal environment for pathogen colonization and growth.
3
How common is rhinosinusitis (RS)?
RS is a major burden on the health care system, with 12% to 15% of adults diagnosed with acute or chronic rhinosinusitis annually in the United States. ARS is the fifth leading indication for antibiotic prescriptions and is responsible for over 5 million ambulatory visits each year in the United States.
4
How common are infectious complications of ARS?
Infectious complications of ARS are rare in immunocompetent individuals, with a rate of less than 0.01% per episode of ARS in children and even less in adults. Orbital complications are more common in children, and in immunocompromised patients (diabetes mellitus, human immunodeficiency virus, immunosuppression due to chemotherapy) the complication rate is likely higher.
5
How can the clinician differentiate acute viral rhinosinusitis (AVRS) from ABRS?
Identifying the presence of ABRS is important for providing appropriate therapy. The main determination is based on the time course of the symptoms. Symptoms of RS that are present for <10 days are more commonly due to viral etiologies. Symptoms that are present for longer or symptoms that initially improved and then worsened are more likely to be bacterial. Symptoms associated with ABRS include purulent nasal discharge and unilateral, localized facial pain.
6
What bacteria are the most common pathogens in ABRS?
Understanding the bacteriology of ARS is paramount for choosing the most effective antibiotic regimen to treat the disease. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (more common in children) are generally accepted as the most common pathogens in this disease. Streptococcus pyogenes, Staphylococcus aureus, gram-negative bacilli, and anaerobes are less common.
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