During his lecture, Dr. Eli O. Meltzer walked his audience through diagnosis and management guidelines of sinusitis/ rhinosinusitis at the ACAAI annual meeting.
Eli O. Meltzer, MD
Part 1 of 2
Eli O. Meltzer, MD, FACAAI, co-director, Allergy & Asthma Medical Group & Research Center, Clinical Professor of Pediatrics, University of California, San Diego, walked his audience through diagnosis and management guidelines of sinusitis/rhinosinusitis at the American College of Allergy, Asthma and Immunology annual meeting.
Rhinosinusitis is common, present in approximately 14% of US population, and in over 40 million adults. Chronic rhinosinusitis has high morbidity, impairing our health, quality of life, productivity, and finances. It is responsible for roughly 6 workday absences (similar to acute asthma), not accounting for days when workers are present but sick.
The subtypes of rhinosinusitis are acute viral rhinosinusitis, acute bacterial rhinosinusitis, chronic rhinosinusitis without nasal polyps, chronic rhinosinusitis with nasal polyps, and allergic fungal rhinosinusitis.
Five consensus guideline documents have been published in past 7 years: the Rhinosinusitis Initiative (2004), the Joint Task Force on Practice Parameters (2005), the Clinical Practice Guideline: Adult Sinusitis (2007), the European Position Paper on Rhinosinusitis and Nasal Polyps (2007), and the British Society for Allergy and Clinical Immunology (2008). Dr. Meltzer cautioned that consensus and divergent opinions occur between within and between guidelines.
The rhinosinusitis nomenclature is somewhat evolving. Four of the five guidelines (all but the Joint Task Force) have adopted the term rhinosinusitis in place of sinusitis. Dr. Meltzer believes that rhinosinusitis and sinusitis should be used interchangeably, because the term rhinosinusitis has been more commonly used only in past decade.
Rhinosinusitis classification historically has been mostly related to symptom duration, but all 5 guideline documents recognize that an assessment of symptom severity is important to define the magnitude of disease and assist with treatment selection. A visual analogue scale (VAS) was validated to the questions “How troublesome are your symptoms of rhinosinusitis?” The scale ranges from 0 (not troublesome) to 10 (worst thinkable troublesome). Scores ≥ 5 correlated with quality of life detriment.
Diagnosis of Acute Rhinosinusitis
Dr. Meltzer stated the 3 major signs or symptoms consistently cited across all guidelines (although there are minor discrepancies) as being primary diagnostic indicators for ARS are nasal congestion, obstruction or blockage; anterior and/or posterior purulent rhinorrhea; and facial pain or pressure.
It is important to distinguish viral and bacterial etiologies. Acute rhinosinusitis is most commonly viral in origin (eg, the common cold). The incidence of acute viral rhinosinusitis occurs 2 to 5 times/year in the average adult, and 8-10/yr in children. Secondary bacterial infection complicates <3% of cases. Dr. Meltzer noted that it can be difficult to differentiate viral vs bacterial acute rhinosinusitis, and offered these suggestions culled from the guidelines (again, there was not unanimous agreement across guideline documents):
Acute viral rhinosinusitis symptoms typically peak within 2 to 3 days of onset, decline gradually, and disappear with 10 to 14 days.
Symptoms persistence >10 days and/or a pattern of initial symptom improvement followed by worsening suggest acute bacterial rhinosinusitis.
Unusually severe symptoms (eg, higher fever, unilateral facial/tooth pain, orbital cellulitis, or intracranial expansion), particularly during first days of disease, also suggest acute bacterial rhinosinusitis.
Note that neither presence of fever nor color of nasal mucus color is useful in differentiating viral from bacterial. (Purulence alone cannot distinguish between viral and bacterial infection, but a diagnosis of acute bacterial rhinosinusitis is unlikely in its absence.)
All guidelines agree plain radiography (eg, Waters view) is neither useful nor cost-effective. Computed tomography is not normally recommend for routine evaluation, but is the preferred imaging option in limited options (eg, severe disease, immunocompromized state, suspected complications before surgery). Nasal endoscopy is better than anterior examination for middle meatus region, sphenoethmoidal recess. While it is not essential for diagnosis of ARS, consider it for treatment failures. Nasal culture is also not recommended for routine work up. Sinus puncture is a standard method for confirming bacterial pathogens in maxillary sinuses; because it is uncomfortable, perform it only when necessary.
Management of Acute Rhinosinusitis
Dr. Meltzer reiterated that <3% of ARS cases are bacterial, yet antibiotics are prescribed for 80-90% of ARS cases, even though 60% of patients would clear themselves. The guidelines recommend antibiotics only for severe illness, for those whose symptoms improve then worsen. They recognize usefulness of intranasal corticosteroids (CS) for ARS. Watchful waiting and symptomatic relief with analgesics are recommended initially. Intranasal CS should first be prescribed for moderate case if symptoms persist or increase >5 days. Antibiotics should be added if no improvement is seen after 14 days. The intent is to reduce unnecessary antibiotic use. Initial combination therapy with intranasal CS plus antibiotics, are appropriate for severe cases. Also, Dr. Meltzer advised that oral CS may be useful for pain relief in severe disease. While decongestants are commonly used for ARS, but the current evidence regarding topical and oral decongestants is limited. Nasal saline irrigation is recommended by most guidelines.
To read our article on the rest of Dr. Meltzer’s lecture, click here…