Hi, my name is Satish Govindaraj, and I'm Director of Rhinology at the Mount Sinai Health System in New York. And welcome again to our course, Acute and Chronic Rhinosinusitis, A Comprehensive Review. Some of you just finished Module One, where we talked about normal sinus anatomy and function. Now walking away with an understanding of how the sinuses normally function, we can move on now to module two, where we'll focus on acute sinusitis. During this module my goal is to give you a practical understanding of how to diagnose as well as to manage acute sinusitis. And my hope is that you walk away with A, an ability to diagnose acute sinusitis reliably. B, distinguish between acute bacterial versus acute viral sinusitis. And C, understand in an evidenced-based fashion the medical management and treatment for acute sinusitis. Let's talk about and define what is rhinosinusitis. And many of us look at it as just an infection. But if you look at here, it's a spectrum of inflammatory and infectious disorders concurrently affecting the nose and paranasal sinuses. So it's not just an infection, but it's about inflammation also. And if you look at that definition, rhinosinusitis, we're gonna use that term interchangeably with sinusitis throughout this module, just so you're aware. Now when we talk about acute versus chronic, these are two completely different disease entities. And the reason why is an acute sinusitis is what we picture a sinus infection to be, a patient holding their head in their hands, a headache, fever, purulent drainage from the nose, just not feeling well. That's the acute sinus infection. Chronic sinusitis is a patient who has these persistent, low-grade symptoms, the mild headache, the persistent post-nasal drip, that just doesn't wanna go away. And their quality of life starts to gradually deteriorate. So although both rhinosinusitis, they are still two separate disease entities. And the way to distinguish the two, first and foremost, is just by the duration of symptoms. Now if you look at acute sinusitis, this is a patient that suffers with symptoms for up to, but not greater than 4 weeks. So that 4 week cutoff is very important to fall under acute. Whereas chronic is a patient who has symptoms for 12 weeks or more. So this persistent symptom goes on and on for over three months. So that's where you need that time course to distinguish between the two. There's certain other conditions, such as a recurrent acute sinusitis, where patients have four or more episodes of acute sinus infections that last seven to ten days. The difference, however, is that these patients have periods of normalcy between the infections, and that distinguishes them from the chronic sinus patient. And lastly, acute sinusitis can occur in the setting of a patient with chronic sinusitis. So the two can coexist with an acute infection being superimposed on this chronic process. So just an understanding and a baseline of how we can distinguish between acute and chronic. Now if you take that one step further, if you look on the top here, ARS stands for acute rhinosinusitis, and here at the picture on the left is a closeup of a left nasal endoscopy. And we see purulent drainage draining from left the middle meatus right here. And we see drainage from that area. As we learned in module one, that can be originating from the maxillary sinus, the anterior ethmoid, or the frontal. But when we get a CAT scan, as you see on the right, we see that the maxillary sinus here has an air fluid level, and this acute process is originating from the maxillary sinus. Now, if you look at the cells here that come in to fight that disease process, you see a Neutrophil, more suggested above the infectious process in the acute sinusitis. Now we go onto chronic sinusitis. This is an endoscopic view, also on the left side. You don't see much normal anatomy, just polyps obliterating that nasal cavity. We get a scan on this patient, and we see complete opacification of the ethmoid and maxillary sinuses here bilaterally. And then when we look at the type of cells that come in to address this condition, we see the eosinophil. So that tells us this is more of an inflammatory process, not the infection. So acute and chronic rhinosinusitis, to answer that question at the top, not the same process. So how do we diagnosis and treat acute rhinosinusitis? That's going to be our focus now with the remainder of this module. And there are certain diagnostic criteria that were put out just in April in 2015 with our academy's Clinical Practice Guidelines. And as we talked about, the duration of symptoms is critical, up to, but not greater then 4 weeks, that's the first. The second is the big three I like to call it, purulent rhinorrhea or purulent drainage is a must. You must have that symptom. And it's not clear mucus draining from the nose. It has to be colored and mucoid to fall under that category. With that symptom, you have to have either nasal obstruction or congestion, or facial pain, pressure, of fullness. So, two symptoms, one of them being purulent drainage with nasal congestion or obstruction or facial pain or fullness. And, lastly, you need to distinguish between a viral sinusitis, as well as from an acute bacterial sinusitis. And the way we do that is looking at your duration of symptoms. A viral sinus infection could have yellow drainage, purulent rhinorrhea, fever, headaches. The distinguishing feature between a virus and a bacteria is essentially duration of symptoms being seven to ten days. A virus can last that degree of time. If you go beyond that seven to ten day period, you're essentially talking about an acute bacterial sinus infection. The one exception is that you see underneath, that a patient has initial improvement for three to four days, and then on day five starts to get worse again. That's something called a double worsening sign. And that's a patient who had that acute viral infection that now has progressed to a bacterial one inside that seven day period, so two ways that we can distinguish between a bacterial versus a viral sinusitis. Now going a step further, if you look at the common cold or an acute viral infection, as we talked about, if you look at the graphs on fever, headache, and nasal obstruction, you see here they tend to go away at day 7 to10 as we discussed. The one thing you have to counsel your patients is that the nasal drainage, as well as the cough, as you see here, will progress up to and even greater than two weeks. So a patient can still have post-nasal drip and cough that goes on beyond ten days and still fall under a viral sinus infection. And that's very important to remember, because they may want antibiotics or get treatment because they feel that infection is still going on. But they're actually getting better. They just have these lingering symptoms that need to go away. And what are the bacterial pathogens that we have to take care of when we're treating acute rhinosinusitis? This study here was done in 2000, and now we're in 2015. And that pie chart is essentially very similar. The most common bacteria still is Strep pneumoniae. The second most common bacteria is Haemophilus influenzae. Hopefully, with vaccinations, etc., over the years, we'll see that number dip down a bit. We're also starting to see more resistant strains to haemophilus influenzae, more so in the Southeast. And that 21% that you see here, the other, we now know that 10% of that group is made up of staph aureus. Staph aureus was a bacteria that was once thought to be in the healthcare world but now has made its way into the community. So it's also a real cause of acute sinusitis. And lastly, Moraxella catarrahalis, also one of the more common organisms and slightly higher in the pediatric population. So how do we treat acute sinusitis? The first response is, oh, it's got to be antibiotics. Well actually, not at all. The first thing is to determine, is a CT necessary? Normally, for the management of acute rhinosinusitis, you do not need a CT scan. The caveat is if there is a complicated case meaning that, is the sinus infection spreading outside the sinuses? In the ethmoid we discussed in module one, it could be spreading to the eye. Do we see any spread from the frontal sinus or the sinus into the brain area? Is the patient lethargic? Did he have severe headaches and neck stiffness? Is there change in mental status? Do we see any facial swelling or redness over the facial area to suggest, wow, this is not just a sinus infection that's localized to the sinuses, but it's spreading outside of that area. That's where we get the cat scan to see what's going on. The first thing the patient is gonna want is pain relief. They're gonna come to your office just to relieve that pain. That is the number one symptom that brings a patient in for care. And NSAIDs, or anti-inflammatories, or acetaminophen should be adequate pain management. If someone is requiring more than that, you have to think is something else going on, rather than this acute sinusitis? Or are you dealing with a complicated acute sinusitis that you don't know about yet? Now what are the adjuncts for symptom control? Decongestants, both topical and oral, have been shown in multiple studies to demonstrate an improvement in symptom severity. So just by being on decongestants allowing the sinuses to drain potentially a little bit easier, it helps decrease some of the symptoms that patients suffer. The one thing with topical decongestants if you use them for more than three to five days, a patient can become reliant on this medication. The effect starts to last less and less, and the patient needs more and more of that topical decongestant to maintain the airway, something called rebound congestion. Topical corticosteroids have also been shown to decrease the symptoms associated with the acute bacterial rhinosinusitis, especially in the patient who may have underlying allergies or who already is on topical steroids. They can be a very useful adjunct to continue during the acute process. Now what about saline irrigations? Multiple studies really showing efficacy. Hypertonic has been shown to be somewhat better than isotonic in decreasing mucosal congestion, decreasing posterior rhinorrhea, as well as promoting and improving ciliary motility. Mucolytics, no real study showing a benefit. However, common sense tells us it's a mucus thinner. It can loosen secretions with very minimal side effects, so often used as an adjunct, very important adequate hydration. Using mucolytics without adequate hydration results in no benefit, so tell patients to hydrate when using that medication. And lastly, antihistamines, no real role for antihistamines. They can thicken the mucus that you already have, making clearance of an acute infection more difficult. The one caveat is a patient who has severe allergies. That's where you'll maintain that antihistamine in order to control the allergies, and hopefully allow that infection to clear. Now finally, we have an acute bacterial infection, and we're gonna talk about antibiotics. Now, what is the role of antibiotics? Actually, you do not have to treat with antibiotics if you're dealing with a patient with a non-severe illness, meaning no fever and mild sinus pain. The new guidelines in April of 2015 actually added that you can hold antibiotics in the severe patient who has fever or severe pain in select cases. And I think the key thing you have to understand is this is a case where follow up is likely. Very important to keep in mind, follow up of that patient is critical if you're going to treat that patient without the antibiotics. One option also is to give the patient the antibiotic to take home, let them see how they do. If they persist, or worsen, then they can fill that prescription at home and it saves them having to come into the office to get a new visit and a prescription at that time. The rationale is, for holding antibiotics, is that 60% of patients really have spontaneous improvement. And if you look at the patients who receive antibiotics and the treatment of acute bacterial sinusitis, the adverse events or outcomes are actually higher in the patients with antibiotics. So those adverse outcomes are related to nausea and vomiting, diarrhea, headaches, all side effects related to the medication. Now what if we use antibiotics? When do we use them? It's really in the patient who's unreliable, you don't know if they're going to follow up. And in the patient who has underlying conditions that may predisposed them to a worse infection. Chronic illnesses such as diabetes, immune suppression from either transplant or an immune deficiency or a patient who's failed multiple courses of antibiotics already. Those are the cases where we may go with antibiotics. And first line antibiotic is Amoxicillin or Augmentin. In patients who are penicillin-allergic, Doxycycline or a respiratory Fluoroquinolone such as Moxifloxacin or Levofloxacin is the antibiotics of choice. Now, a second line agent, someone who may have been on Augmentin or an Amoxicillin who failed, the next line of treatment is Augmentin XR. As well as the respiratory Fluoroquinolone, such as Levaquin or Levofloxacin or Moxifloxacin, the trade name Avelox. This is important to keep in mind because now, as we talked about their drug-resistant strains or beta-lactamase-producing organisms, with haemophilus influenzae as well as penicillin resistant strains of strep pneumonia. So you really have to follow these patients to make sure they're improving, once you put them on antibiotics. The usual duration is ten days. Studies have shown that adverse outcomes with antibiotics are better if you keep them on antibiotics for five days or less. The time where five days is acceptable, is when you have a mild infection, and a patient who doesn't have a setup for potentially more severe infections. Now, when would you use Augmentin over Amoxicillin as the first line treatment? In that last slide we talked about either one as an option, right? So, where would use Augmentin? Someone who's failed antibiotic therapy already, someone who's already been on antibiotics in the last month. That's where they've already failed one treatment, better to go to the next line such as augmentin. If they live in a place where there's resistant bacteria, beta-lactomase producing haemophilus influenzae, penicillin resistant strep pneumonia. That's the one where you may go right to something stronger. Someone who' a healthcare worker, or who has family who's in the healthcare industry where they may potentially be exposed to more resistant organisms. And patients with a frontal or a sphenoid sinusitis, in module one, we talked about how there's critical things around these sinuses. So you want to be aggressive when you're treating it to hopefully eradicate that infection and not allow it to spread beyond those areas. And lastly associated conditions such as patients with immunocompromise, patients who are older, 65 years and over, and patients who may have chronic illness such as diabetes. Those are the patients where we may need to be more aggressive with treatment and not allow them to have a infection that festers and persists for a prolonged period of time. So let's summarize what we learned about an acute sinusitis. One is key thing is 4 weeks, but not greater, symptoms last up to that time. Second is the big three. They must have purulent drainage, but they can have either nasal obstruction or facial pain or pressure, as another diagnosis. So very important, you can make the diagnosis of acute sinusitis just with a good history and physical. You don't need a fancy imaging or a scope, by just by going after that big three. You got to distinguish between a viral versus a bacterial sinusitis. We know how to do that, the time duration of seven to ten days is critical. And lastly how do we treat sinusitis in the non-severe case? Adjuncts only are a reasonable option. Antibiotics come in if the infection persists. And even for severe infections, the new guidelines say watchful waiting with adjuncts is an option, but you have to a reliable patient. And you have to have the right candidate, someone who's not setup for worse infections, such as the immunocompromised patient. I hope you all enjoyed our review of acute rhinosinusitis where we discussed both the diagnosis and the management. Module three, the next module, will focus on the diagnosis and management of chronic rhinosinusitis, and we hope you will join us for that module. Thank you.
