Infectious Disease Compendium

Sinusitis

(2016 Review)

Diagnosis

Infection of the sinus. A clinical diagnosis most of the time, a CT is the best way to diagnose radiographically.

Epidemiologic Risks

Life, tubes in the nose, immotile cilia, immunoglobulin deficiency, allergies.

Microbiology

- Acute: Streptococcus pneumoniae and/or Haemophilus influenzae (unencapsulated) (the big 2), then alpha-Streptococci, Moraxella catarrhalis, anaerobes, S. aureus.

- Chronic: can be anything, so get cultures, S. aureus, gram negative rods like Pseudomonas aeruginosa, anaerobes.

- Non tuberculous mycobacteria may be a cause of refractory rhinosinusitis, acquired for the tap water used to irrigate the nose (PubMed).

- Nosocomial: S. aureus and Gram negative rods like Pseudomonas aeruginosa.

- Immunoincompetent: all the above PLUS aspergillus or mucormycosis or other molds.

In AIDS patients; Aspergillus often invades into brain and kills (Pubmed).

Empiric Therapy

- Acute: Neither amoxicillin nor budesonide alter the course of acute maxillary sinusitis (PubMed). Since placebo is no different than antibiotics, no reason to give antibiotics (PubMed).

Does not need therapy if symptoms do not persist for less than 7 days. But try telling that to a patient. If symptoms persist greater than 7 days, then or amoxicillin. OR trimethoprim/sulfamethoxazole OR amoxicillin./clavulanate OR clarithromycin OR azithromycin OR cefdinir OR cefpodoxime OR cefuroxime OR levofloxacin OR moxifloxacin for 10 days are approved based on current recommendations

Me? I think damn near anything will work in most patients most of the time. Some old German studies demonstrated that most of the time in most patients, it is a self limited disease. But we must follow the guideline, n'est pas?

The downside of not treating these infections is less the sinusitis and more the old complications: brain abscess, cavernous sinus infections, Potts Puffy Tumor (chronic frontal sinus osteomyelitis with abscess), meningitis, etc. In my experience (the three most dangerous words in medicine), these diseases are increasing as we use less inappropriate outpatient antibiotics.

- Chronic: let cultures be you guide. Call ENT to punch some holes in the sinus. Interesting that the drainage holes are at the top of sinus; that intelligent designer done forget about gravity. Guess he was preoccupied.

- Nosocomial: get the tube out and let cultures be you guide. Usually third generation cephalosporins OR carbapenem OR piperacillin OR penicillin/beta-lactamase inhibitors. If penicillin allergic aztreonam OR quinolone ALSO give at least one 5-7 mg/kg dose of aminoglycoside. All plus/minus vancomycin.

- Immunoincompetent: let cultures be you guide.

Pearls

Recurrent sinusitis in the relatively young ( < 50 or so): check quantitative immunoglobulins and IgG subtypes, you just may get lucky. If it is a female and they have a child, do not worry about immotile cilia syndromes.

Rants

Do not forget Wegener's. Old people do not get sinusitis (or otitis media for that matter). They get Wegener's.