Acute rhinosinusitis Presented by Sasikarn Suesirisawad, MD.

1. Acute rhinosinusitis
EPOS 2012
IDSA Guideline for ABRS 2012
Sasikarn Suesirisawad, MD

2. EPOS: 2007 VS 2012
Content 2007 2012
Definition Divided into adult/children
Classification Acute non-viral rhinosinusitis Acute post viral
rhinosinusitis
Defined ABR
Epidemiology More study
Factor associated with ARS More evidence
Additional lab Mucocillary function Procalcitonin
Nasal airway assessment ESR
Algorithm and Transformation
Evidence of treatment

3. ARS in primary care studies
0.2 -1.8%
3.4 %
6-10%
Recurrent ARS: 0.035%
14%
EPOS March 2012

4. ARS in secondary care studies
16.4%
1.4%
7%
EPOS March 2012

5. EPOS: Categories of Evidence
 Ia: meta-analysis of RCTS
 Ib: at least 1x RCT
 IIa: at least 1x controlled study w/out
randomization
 IIb: at least 1x other type of quasi-experimental
study

6. EPOS: Strength of Recommendations
 A = directly based on category I evidence
 B = directly based on category II evidence, or
extrapolated from category I evidence
 C = directly based on category III evidence or
extrapolated from category I or II evidence
 D = directly based on category IV evidence or

7. Acute rhinosinusitis in adults
 Inflammation of nose and paranasal sinuses
 ≥ 2 symptoms, one of nasal blockage/
obstruction/congestion or nasal discharge (a
nt/post nasal drip):
 ± facial pain/pressure
 ± reduction or loss of smell
 And either
EPOS March 2012

8. Acute rhinosinusitis in children
 Inflammation of nose and paranasal sinuses
 ≥ 2 symptoms one of nasal blockage/
obstruction/congestion or nasal discharge (a
nt/post nasal drip):
 ± facial pain/pressure
 ± cough
 And either
EPOS March 2012

9. Conventional Criteria for Diagnosis of Sinusitis
Based on Presence of at Least 2 Major or 1 Major and
2 Minor Symptoms
IDSA Guideline for ABRS: CID.March 20, 2012

10. Severity of disease in adult and
children
 Define disease severity:
 Mild: VAS 0-3
 Moderate: VAS 4-7
 Severe: VAS 8-10
EPOS March 2012

11. Classification of ARS in adult/
children
 Common cold/ acute viral rhinosinusits :
duration of symptoms for< 10 d
 Acute post-viral rhinosinusitis:
increase of symptoms after 5 d or persistent symptoms after 10 d wi
th < 12 wk duration.
 ABS: ≥ 3 symptoms/signs
 Discoloured discharge (unilat predominance) and purulent secretion in nasi
 Severe local pain (unilat predominance)
 Fever (>38 °C)

12. Natural history & time course of fever and RS symptom
associated with uncomplicated viral URI in children
IDSA Guideline for ABRS: CID.March 20, 2012

13. Acute rhinosinusitis can be divided into Common Cold
and post- viral rhinosinusitis. A small subgroup of post-viral
rhinosinusitis is caused by bacteria (ABRS).

14. Postviral acute rhinosinusitis Signs of ABS
At least 3 of:
Increase in symptoms after 5 d
-Discoloured d/c
-Severe local pain
-Fever
Persistent symptom after 10 d -Elevated ESR/CRP
-Double sickening
EPOS March 2012

15. I: Which clinical Presentations Identify
Acute Bacterial Vs Viral Rhinosinusitis ?
 Onset with persistent S/S compatible with ARS ≥
10 d without any evidence of clinical improvement.
 Onset with severe S/S of high fever ≥ 39 °C and
purulent nasal discharge or facial pain at least 3–4
consecutive d at beginning of illness.
 Onset with worsening S/S characterized by new
onset of fever,IDSA Guideline for ABRS: CID.March 20, 2012 in nasal dischar
headache, increase

16. Factors associated with ARS
 Environmental Exposures
 Anatomical factors
 Allergy
 Ciliary impairment
 Primary Cilia Dyskinesia
 Smoking
 Laryngopharyngeal reflux
EPOS March 2012

17. Environmental Exposures
 Exposure to individual with respiratory
complaints was risk factor for RS
infection(adjusted OR = 3.7).
 Increased levels of dampness in home has
been associated with sinusitis.
 Exposure to air pollution, irritants used in
preparation of pharmaceutical products,
EPOS March 2012

18. Anatomical factors
 Anatomical variations including Haller cells
and septal deviation, nasal polyps, and
choanal obstruction by benign adenoid tissue
, or odontogenic sources of infections.
EPOS March 2012

19. Ciliary impairment
 Ciliary function diminished during viral and
bacterial rhinosinusitis.
 Exposure to cigarette smoke and allergic
inflammation has been shown to impair ciliar
y function.
 Impaired mucociliary clearance in AR
patients predisposes patients to ARS
EPOS March 2012

20. Smoking
 Active smokers with on-going allergic
inflammation have increased susceptibility to
ARS compared to non-smokers with on-goin
g allergic inflammation, suggesting that expo
sure to cigarette smoke and allergic inflamm
ation is mediated via different and possibly s
ynergistic mechanisms.
EPOS March 2012

21. Laryngopharyngeal reflux
 Pacheco-Galvan et al. 1997-2006 have shown
significant associations between GERD and
sinusitis.
 Recent systematic review, Flook and Kumar
showed only poor association between acid
reflux, nasal symptoms, and ARS
EPOS March 2012

22. Anxiety and depression
 Poor mental health, anxiety, or depression is
associated with susceptibility to ARS
 Mechanisms are unclear.
EPOS March 2012

23. Drug resistance
 Amoxicillin is the most commonly used
antibiotic for mild ARS.
 Increasing resistance to amoxicillin,
particularly in S. pneumoniae and
H. influenzae infections.
EPOS March 2012

24. Concomitant Chronic Disease
 Concomitant chronic disease (bronchitis,
asthma, CVS disease, DM, CA) in children has
been associated with increased risk of develo
ping ARS secondary to influenza.
EPOS March 2012

25. Microbiology of viral (common
cold), postviral, and bacterial ARS
 Viruses.
 Rhinoviruses (50%) and coronaviruses.
 Influenza viruses, parainfluenza viruses,
adenovirus, RSV, enterovirus.
 Bacteria.
 S. pneumoniae, Haemophilus influenza,
M. catarrhalis and S. aureus.
 Streptococcal species , anaerobic bacteria
EPOS March 2012

26. Investigation

27. Bacteriology
 Microbiological investigations are not
required for diagnosis of ARS in routine
practice.
 May be required in research settings, or in
atypical or recurrent disease
EPOS March 2012

28. Prevalence (Mean Percentage of Positive Specimens)
of Pathogens From Sinus Aspirates in ABS
IDSA Guideline for ABRS: CID.March 20, 2012

29. XVI. Should Cultures Obtained by Sinus Puncture or
Endoscopy, Cultures of Nasopharyngeal Swabs Sufficient?
 Cultures be obtained by direct sinus aspiration
rather than by nasopharyngeal swab (strong, mo
derate).
 Endoscopically guided cultures of middle meatus
may be considered as alternative in adults, but th
eir reliability in children has not been established
(weak, moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

30. C-Reactive Protein (CRP)
 Raised in bacterial infection.
 Limiting unnecessary antibiotic use.
 ARS: low or normal CRP may identify low
likelihood of positive bacterial infection
 CRP levels are significantly correlated with
EPOS March 2012

31. ESR
 ESR levels correlated with CT changes in ARS
 ESR >10 is predictive of sinus fluid levels or
sinus opacity on CT scan.
 Raised ESR is predictive of positive bacterial
culture on sinus puncture or lavage
EPOS March 2012

32. Procalcitonin
 More severe bacterial infection
 There is no evidence of its effectiveness as a
biomarker in ARS.
EPOS March 2012

33. Nasal Nitric Oxide (NO)
 Sensitive indicator of presence of
inflammation and ciliary dysfunction.
 Very low levels: primary ciliary dyskinesia,
insignificant sinus obstruction.
 Elevated levels: inflammation provided
ostiomeatal patency maintained.
EPOS March 2012

34. Nasal endoscopy
 Nasal endoscopy may be used to visualize
nasal and sinus anatomy and to provide
biopsy and microbiological samples.
EPOS March 2012

35. Imaging
 CT scan
 Modality of choice to confirm extent of pathology
and anatomy.
 Very severe disease, immuno-compromised pt,
suspicion of complications.
 Routine CT scan in ARS little useful information
 Plain sinus X Rays
EPOS March 2012

36. XVII. Which Imaging Is Most Useful for Severe ABRS
who suspected to have Suppurative complication?
 CT rather than MRI is recommended to
localize infection and to guide further treatm
ent (weak, low).
IDSA Guideline for ABRS: CID.March 20, 2012

37. Differential Diagnosis of ARS
 Viral Upper Respiratory Tract Infection
 Allergic rhinitis
 Orodontal disease
 Rare diseases
 Intracranial sepsis
 Facial pain syndromes
 Vasculitis
EPOS March 2012

38. Warning signs of complications of
ARS
EPOS March 2012

39. Management of ARS
 ARS resolves without antibiotic treatment in
most cases.
 Symptomatic treatment and reassurance is
the preferred initial management strategy fo
r patients with mild symptoms.
 Antibiotic therapy should be reserved for
high fever or severeMarch 2012
EPOS (unilateral) facial pain.

40. Systemic review/meta-analysis for ATB in ARS
EPOS March 2012

41. II: When Should ATB Initiated
in Pt With S/S Suggestive of
ABRS? ATB be initiated as soon as clinical
 Empiric
diagnosis of ABRS is established as defined in
recommendation 1 (strong, moderate)
IDSA Guideline for ABRS: CID. March 20, 2012

42. III: Should Amoxicillin Vs Amoxi-Clav
Used for Initial ATB of ABR in
 Amoxi-clav rather than amoxicillin alone
Children?
recommended as empiric antimicrobial thera
py for ABRS in children
 (strong, moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

43. IV: Should Amoxicillin Vs Amoxi-
Clav used for Initial ATB of ABR in ad
ults?
 Amoxi-clav rather than amoxicillin alone is
recommended as empiric ATB for ABRS in ad
ults
 (weak, low).
IDSA Guideline for ABRS: CID.March 20, 2012

44. V: When Is High-Dose Amoxi-Clav
Recommended Initial ATB for ABR ?
 ‘‘High-dose’’ (2 g/d or 90 MKD bid) amoxi-clav
recommended for children and adults with ABRS
 High endemic rates (≥10%) of DRSP
 Severe infection
( systemic toxicity
IDSA Guideline for ABRS: CID.March 20, 2012

45. VI: Should quinolone Vs B-Lactam used
1°-line for Initial ATB of ABR?
 B-lactam (amoxi-clav) rather than respiratory
fluoroquinolone recommended for initial
empiric antimicrobial therapy of ABR
 (weak, moderate)
IDSA Guideline for ABRS: CID.March 20, 2012

46. VII: Besides quinolone, Should Macrolide, bactrim,
doxycycline, 2°/3° Gen Cep Used 2° -line for ABR?
 Doxycycline may be used alternative in adults because it remains active against
RS pathogens and has excellent PK/PD (weak, low).
 2°/3° oral Gen Cep: no longer recommended for empiric monotherapy of ABRS
due to resistance S. pneumoniae. Combination tx with 3° oral Gen plus clindamy
cin may be used as 2°-line for children with non–type I penicillin allergy or high en
demic rates of PNS S. pneumoniae (weak, moderate).
 Not recommended
 Macrolides: high rates of resistance S. pneumoniae (30%) (strong, moderate)
IDSA Guideline for ABRS: CID.March 20, 2012

47. VIII. Which ATB Recommended for ABRS
in Adults/Children with Penicillin Allergy?
 Adults:
 Either doxycycline or quinolone(levofloxacin/
moxifloxacin)
 (strong, moderate)
 Children:
 Levofloxacin: type I hypersensitivity to penicillin
 Clindamycin + 3° oral Gen Cep (cefixime/cefpodoxime):
non–type I hypersensitivity CID.March 20, 2012
IDSA Guideline for ABRS:
to penicillin

48. IX: Should Coverage for S. aureus Be
Provided Routinely during Initial Empiric ATB
of ABR?
 S. aureus (including MRSA) is one of
potential pathogen in ABRS
 Routine ATB coverage for S. aureus or MRSA
during initial empiric therapy of ABRS is not r
ecommended (stro
ng, moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

49. X: Should empiric ATB be administered
for 5–7 d vs 10–14 d?
 Uncomplicated ABRS in adults: 5–7 days
(weak, low-moderate).
 Children with ABRS: 10–14 days
(weak, low moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

50. XIV: How Long Should Initial Empiric ATB in
Absence of Clinical Improvement Be Continued Befo
re Considering Alternative Management?
 Alternative management strategy is
recommended if symptoms worsen after 48–
72 hrs of initial empiric ATB or fail to improve
despite 3–5 d of initial empiric ATB
 (strong, moderate)
IDSA Guideline for ABRS: CID.March 20, 2012

51. XV: What Is Recommended in Who Worsen Despite 72 Hr
or Fail to Improve After 3–5 D of Initial Empiric ATB?
 Should be evaluated for possibility of
resistant pathogens, noninfectious etiology,
structural abnormality, or other causes for tre
atment failure
 (strong, low).
IDSA Guideline for ABRS: CID.March 20, 2012

52. INS in ARS
EPOS March 2012

53. INS & ATB in ARS
EPOS March 2012

54. INS VS placebo for adults/children with ABS
IDSA Guideline for ABRS: CID.March 20, 2012

55. XII: Are INS Recommended as
Adjunct to ATB in ABR?
 INS recommended as adjunct to ATB,
primarily in patients with history of AR
 (weak, moderate)
IDSA Guideline for ABRS: CID.March 20, 2012

56. Oral corticosteroids adjunct
therapy
 Cochrane analysis suggests that oral steroids
as adjunctive therapy to oral antibiotics are e
ffective for short-term relief of symptoms (he
adache, facial pain, nasal decongestion and) i
n ARS
 Evidence level Ia
EPOS March 2012

57. Oral antihistamines
 No indication for use of AH(both intranasal
and oral) in treatment of post viral ARS,
except in co-existing allergic rhinitis.
EPOS March 2012

58. Nasal decongestants
 27 trials (5,117 participants) of RCT:
effectiveness of common cold treatments
 AH, analgesic-decongestant combinations
have some general benefit in adults and older
children (recommendation A).
 Weighed benefits against risk of adverse
effects. EPOS March 2012

59. XIII: Should Topical or Oral Decongestants or
AH Be Used as Adjunctive Tx in ABR?
 Neither topical nor oral decongestants and/or
AH recommended as adjunctive treatment in
patients with ABRS (strong, low-moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

60. Nasal or antral irrigation
 Nasal douching with saline solution has
limited effect in adults with ARS (lev
el of evidence Ia).
 Effective in children with ARS in addition to
standard medication (level of evidence Ib) an
d can prevent recurrent infections (level
of evidence IIb)
EPOS March 2012

61. XI: Is Saline Irrigation of Benefit as
Adjunctive Tx in ABR?
 Intranasal saline irrigation(physiologic /
hypertonic saline) recommended as an adjun
ctive treatment in adults with ABRS (weak, lo
w-moderate).
IDSA Guideline for ABRS: CID.March 20, 2012

62. Heated, humidified air
 Steam may help congested mucus drain
better and heat may destroy cold virus as it d
oes in vitro.
 Steam inhalation has not shown any
consistent benefits in treatment of common
cold, hence is not recommended in routine tr
eatment of common cold symptoms
EPOS March 2012

63. Interventions to interrupt spread
of viruses in viral rhinosinusitis
 Handwashing, esp around younger children.
 Incremental effect of adding antiseptics to
normal handwashing to decrease respiratory
disease remains uncertain.
 Barriers to transmission, isolation, hygienic
measures are effective at containing RS virus
epidemics. EPOS March 2012

64. Ipratropium bromide
 Likely to be effective in ameliorating
rhinorrhoea.
 Recommendation A
EPOS March 2012

65. Probiotics
 Probiotics were better than placebo in
reducing number of acute URTIs, rate ratio of
and reducing antibiotic use
 Recommendation A
EPOS March 2012

66. Vaccination
 No direct effect in treatment of ARS.
 Affected frequency and bacteriology of AOM
and ABS
 Causative pathogens of ABS in children in 5 y
after introduction vaccination PCV7 as
compared to previous 5 y. Proportion of
S. pneumoniae declined by 18%, H.influenza
EPOS March 2012

67. NSAID’s, Aspirin or
acetominophen
 NSAID did not significantly reduce TSS, or
duration of colds.
 Outcomes related to analgesic effects of
NSAID (headache, ear pain, muscle, jt pain).
 No evidence of increased frequency of
adverse effects in NSAID tx groups.
EPOS March 2012

68. Zinc
 Zinc would shorten duration of episode of
common cold and prevention risk of developi
ng episode of common cold.
 Too early to give general recommendations
for use of zinc because not sufficient knowle
dge optimal dose, formulation and duration o
f treatment
EPOS March 2012

69. Algorithm for
management
of ABS
IDSA Guideline for ABRS: CID.March 20, 2012

70. EPOS2007
EPOS March 2012

71. Treatment adult with ARS
EPOS2007

72. EPOS2007
EPOS March 2012

73. EPOS March 2012

74. Treatment children with ARS
EPOS 2007

75. ATB for ARS in children
EPOS March 2012

76. Ancillary therapy for ARS in
children
EPOS March 2012

77. 40-50MKD 80-90MKD

79. THANK YOU

80. Indications for Referral to
Specialist
IDSA Guideline for ABRS: CID.March 20, 2012