Primary Care Otolaryngology

Rhinology, Nasal Obstruction, and Sinusitis

Acute Bacterial Rhinosinusitis Prolonged mucosal edema, from whatever etiology causes sinus obstruc- tion and retention of secretions, may lead to acute bacterial rhinosinus- itis . Patients may exhibit several of the major symptoms (facial pressure/ pain, facial congestion/fullness, purulent nasal discharge, nasal obstruc- tion, anosmia) and one or more of the minor symptoms (headache, fever, fatigue, cough, toothache, halitosis, ear fullness/pressure). Radiographic studies (plain films or CT scans) do not differentiate acute bacterial rhi- nosinusitis from a viral upper respiratory infection (URI). More than 80 percent of patients with a viral URI also have an abnormal sinus CT scan. Time will usually differentiate a bacterial from a viral infection. It usually takes 7–10 days for a viral infection to resolve. Symptoms lasting beyond 7–10 days, or worsening after 5 days, suggest that bacterial infection is being established. The organisms responsible are similar to the organisms that cause acute otitis media and include Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis . By definition, acute

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rhinosinusitis persists less than one month, and subacute rhinosinusitis lasts more than one month but less than three months. Chronic sinusitis is defined by symptoms that persist more than three months, and usually has a different underlying microbiol- ogy with increased numbers of anaer- obic organisms. The treatment of choice for acute rhi- nosinusitis (as well as acute otitis media) has been a 10-day course of either amoxicillin or trimethoprim/ sulfamethoxazole. Resistance to amoxicillin has prompted some physi- cians to consider using amoxicillin/ clavulanate or a second-generation cephalosporin or macrolide or a qui- nolone instead of amoxicillin as the first-line therapy. More recently, the

Figure 9.1. Acute rhinosinusitis. Note purulent drainage extending from the middle meatus over the inferior turbinate. Symptoms persisting longer than 7–10 days suggest bacterial infection, and antibiotic therapy is indicated.

appearance of penicillin resistance in S. pneumoniae infection (which has a different resistance mechanism than beta-lactamase production) has resulted in the recommendation that higher doses of amoxicillin be used routinely. Drugs that do not adequately cover H. influenzae are inappro- priate treatment for either otitis media or rhinosinusitis. Adjunctive

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